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Open Tent B'nai Mitzvah Registration
Student Information:
Name
*
Contact Information
*
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Zip Code
Preferred Phone number
*
Phone Type
Cell
Work
Home
Email
*
Alternative Phone number
Phone Type
Cell
Work
Home
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
*
mother
father
step-mother
step-father
other
Please specify:
Same Address as student above?
*
Yes
No
Contact Information
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Preferred Phone number
*
Phone Type
Cell
Work
Home
Email
*
Alternative Phone number
Phone Type
Cell
Work
Home
Occupation
How did you hear about JYW / Rabbi Brian?
*
Add another Parent / guardian
Name
*
Relationship to student
*
mother
father
step-mother
step-father
other
Please specify:
Same address as student above?
*
Yes
No
Contact Information
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Preferred Phone number
*
Phone Type
cell
work
home
Email
*
Alternative Phone number
Phone Type
cell
work
home
Occupation
Add another Parent / guardian
Name
*
Relationship to student
*
mother
father
step-mother
step-father
other
Please specify:
Same address as student above?
*
Yes
No
Contact Information
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Preferred Phone number
*
Phone Type
cell
work
home
Email
*
Alternative Phone number
Phone Type
cell
work
home
Occupation
Add another Parent / guardian
Name
*
Relationship to student
*
mother
father
step-mother
step-father
other
Please specify:
Same Address as student above?
*
Yes
No
Contact Information
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Preferred Phone number
*
Phone Type
cell
work
home
Email
*
Alternative Phone number
Phone Type
cell
work
home
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:
$250
$500
Other
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.
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