Bar Mitzvah Application

Full Name*

First NameLast Name

Birth Date*

MonthDayYear

Time of Day:*

HourMinutes

Hebrew Name:*

Address*

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

Phone Number*

Area CodePhone 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:*

MonthDayYear

*

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

Bar/Bat Mitzvah Preparation Fee with the Rabbi:*

$60/per lesson

For boys only: Tefillin*Due 3 months prior to the Bar Mitzvah Date

$375 (Basic Kosher Teffilin)$575 (Regular Kosher Teffilin)$875 (Premium quality kosher Tefillin)

One time building usage/service fee:*

$500 to be paid directly to the Chabad House

250Option 2Option 3

I would like to make a donation to the Rabbi officiating the service in the amount of:*

$720$500$360

Total

$0.00

Payment

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Guidelines:

Payments: