Bar/Bat Mitzvah Registration

Student's Name *
Student's Name
Address *
Home Phone *
Home Phone
Child's Birthdate *
Child's Birthdate
Mother's Name *
Mother's Name
Mother's Cell *
Mother's Cell
Father's Name *
Father's Name
Father's Cell *
Father's Cell
(Other children in family not attending MiYaD)
Is there any conversions or adoptions in the child's family, past or present? *
Is the natural mother of the child Jewish? *
Pediatrician Name *
Pediatrician Name
Pediatrician Phone Number *
Pediatrician Phone Number
Has your child had any previous Hebrew/Judaic Education? *
I (WE) HEREBY ENROLL OUR CHILD IN MiYaD Bar/Bat Mitzvah Lessons. We agree to pay the entirety of tuition or weekly payment enumerated for our lessons or service. We commit to holding ourBar/Bat Mitzvah service in accordance with Jewish Law according to the Torah, in coordination with Rabbi Chanan Krivisky. IN THE EVENT OF A MEDICAL EMERGENCY AND NEITHER PARENT CAN BE REACHED, MEDICAL TREATMENT MAY BE PROVIDED AS NECESSARY. MY (OUR) CHILD MAY BE PHOTOGRAPHED AND THE PICTURES MAY BE USED FOR PUBLICATION BY MiYaD. *
Checking the box below you will be as legally binding as a printed signature.
Date *
Date of Affirmation of Application: