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Bar Mitzvah Lesson Registration

Child Full Name

First Name Last Name
Hebrew Name If Known
Birth Date

Month Day Year
School Attending
Bar Mitzvah Celebration Date
Was the natural mother born Jewish?

Yes No
Were there any conversions in the family?

Yes No
If yes - who was the Rabbi?
Temple / Synagogue affiliation (if applicable)
Parent Information

Address

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

Phone Number

Area Code Phone Number
E-mail
Father Name

First Name Last Name
Father Cell Phone Number

Area Code Phone Number
Father Email
Mothers Name

First Name Last Name
Mother Cell Phone Number

Area Code Phone Number
Mother Email
Should be Empty:

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