Bar Mitzvah Club

Time: Tuesdays 6:00pm - 7:30pm

Location: JNY 465 Patricia Ave.

Cost: $60 month (scholarships available)

Parent of youth program participant

Please fill in the contact information of the parent filling in the form

Parent 1 First Name *

Parent 1 Last Name *

Cell Number *

Email *

Event Fee(s)

Per Month

$ 60.00

Total Fee(s)

Credit Card Information

Card Type

Card Number *

Security Code *

Expiration Date *

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *

Child's info

Please fill in your child's name and date of birth

First & last name *

Child's Date of Birth

Parent 2 contact info

Please fill in the contact info of parent 2

Parent 2 First Name

Parent 2 Last Name

Parent 2 cell

Comments

Please enter any notes or comments

Comment