Bar Mitzvah Application

Full Name*
First Name Last Name
Birth Date*

Month Day Year
Time of Day: *
Hour Minutes
Hebrew Name: *

Address*

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

Phone Number*

Area Code Phone Number
Parent's E-mail*
Father's Name: *
Mother's Name:*
Is the natural mother of the child Jewish?*
Is the maternal grandmother Jewish?*
Is the maternal great-grandmother Jewish?*
Father's Hebrew Name: *
Mother's Hebrew Name:*
Maternal Grandmother's Hebrew Name:*
Maternal Great-Grandmother's Hebrew Name:*
Have there been any conversions or adoptions in the family history?* ** If yes, please send all information and documentation.
** Please note: All conversions must be made through a registered Beth Din that is certified by the Rabbinate of Israel.
Preferred Bar/Bat Mitzvah Date:*

Month Day Year
Guidelines:
*

I agree that all food and catering associated with this Bar Mitzvah Celebration will be in accordance with Kosher standards.
*

Bar / Bat Mitzvahs will be done on or after the child’s Hebrew Birthday 12 years old for a girl & 13 years old for a boy
*

My child will stay involved with Cteen Jr. for the following year
*

For boys: My child will continue to attend the Monthly Teffilin club after his Bar Mitzvah
Payments:
Bar/Bat Mitzvah Preparation Fee with the Rabbi:*

$70-80 per lesson (45 min - 1 hour)
Tefillin Due 3 months prior to the Bar Mitzvah Date

$750 (Basic Kosher Teffilin)$875 (Regular Kosher Teffilin)$1050 (Premium quality Kosher Tefillin)
One time building usage/service fee:*

$500 to be paid directly to the Chabad House
$250 to be paid with completion of this application. Remainder to be paid 30 days prior to Bar Mitzvah Date.
Building Usage Fee*

Pay 250 deposit room feePay total room fee now
I would like to make a donation to the Rabbi officiating the service in the amount of: Will be charged a month prior to the service*

$360.00$500.00$800.00$1,300.00
Total

$750.00

Payment

Credit Card

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

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

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Guidelines:

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