Bat Mitzvah Club

Student Information
Child's Name*
First Last
Date of Birth*
Month
Day
Year
Current Residence Information
Address*
Street Address Address Line 2 City State ZIP Code
Parent Information
Father's Name*
First Last
Father's Cell Phone Number
Father's Email Address
Mother's Name*
First Last
Mother's Cell Phone Number
Mother's Email Address
Marital Status
- Married
- Divorced
- Single Parent
Any conversions in the family?
- No
- Yes, Mother
- Yes, Father
Note: Please email any and all paperwork associated with the conversion to rabbim@waysideshul.org
Who was the rabbi that helped the conversion process?
With which Beth-Din (Jewish Court) was the conversion done with?
What was the date of the conversion?
Emergency Contact
Emergency Contact #1 Name*
First Last
Emergency Contact #1 Phone*
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
Course Fee
The annual fee is $500. There will be a trip which we will be asking for a small charge to cover the expense.
Course Fee*
Price:
Total
$0.00
Credit Card
Card Details
Cardholder Name
Notes
Please inform us about any other vital information you think we may need to know about your child.

Student Information