Open Tent B’nai Mitzvah Registration

Student Information:

Name*

Contact Information*

Street AddressCityStateZip Code

Preferred Phone number*

Phone Type

Email*

Alternative Phone number

Phone Type

Date of Birth*

Gender*

Lives with*

School*

Grade*

Hebrew Name (if known)

Previous Jewish education*

Parent Information (please include all parents or guardians):

Name*

Relationship to student*

Please specify:

Same Address as student above?*

Yes
No

Contact Information*

Street AddressCityStateZip Code

Preferred Phone number*

Phone Type

Email*

Alternative Phone number

Phone Type

Occupation

How did you hear about JYW / Rabbi Brian?*

Add another Parent / guardian

Name*

Relationship to student*

Please specify:

Same address as student above?*

Yes
No

Contact Information*

Street AddressAddress Line 2CityStateZip Code

Preferred Phone number*

Phone Type

Email*

Alternative Phone number

Phone Type

Occupation

Add another Parent / guardian

Name*

Relationship to student*

Please specify:

Same address as student above?*

Yes
No

Contact Information*

Street AddressCityStateZip Code

Preferred Phone number*

Phone Type

Email*

Alternative Phone number

Phone Type

Occupation

Add another Parent / guardian

Name*

Relationship to student*

Please specify:

Same Address as student above?*

Yes
No

Contact Information*

Street AddressCityStateZip Code

Preferred Phone number*

Phone Type

Email*

Alternative Phone number

Phone Type

Occupation

Goals:

Please describe the kind of experience you’d like your child to have.*

What about this program interested you?*

Siblings

Name

Age

Gender

Name

Age

Gender

Name

Age

Gender

Payment for Services

If you have already confirmed your class registration and payment amount with Rabbi Brian, you may submit a payment here. You may also pay by check. Please contact Rabbi Brian with any questions.

Your payment amount:

Other amount:

When you click on Submit, you will be taken to a secure PayPal page. You do not need a PayPal account to pay by credit card. You will receive email confirmations from both JYW and PayPal.