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BMC Register

Student Information
Full Name*
First Name Last Name
Jewish Name If available
Date of Birth*

Month Day Year
Home Phone *

Area Code Phone Number

Address*

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

E-mail
Phone Number
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 Name Hebrew Name
Mother's Email*
Mother's Cell*

Area Code Phone Number
Father's Name*
First & Last Name Hebrew Name
Father's Email*
Father's Cell*

Area Code Phone Number
Payment & Fees:
Membership Fee: $120 includes all sessions, supplies and fees.
Total

$0.00

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

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