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Youth Bat Mitzvah Club

BMC Register

Student Information
Full Name*
First NameLast Name
Jewish NameIf available
Date of Birth*
MonthDayYear
Home Phone*
Area CodePhone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Do you like being in a leadership position?*
YesNo
What are some things you hope the BMC will offer?*
Which of these do you enjoy most?*
Parent Information
Mother's Name*
First & Last NameHebrew Name
Mother's Email*
Mother's Cell*
Area CodePhone Number
Father's Name*
First & Last NameHebrew Name
Father's Email*
Father's Cell*
Area CodePhone Number
Payment & Fees:
Membership Fee: $120 includes all sessions, supplies and fees.
Total
$0.00

Payment*

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Should be Empty:

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