Mazel Tov on this important milestone! Share a few details with us so we can begin planning your Bar/Bat Mitzvah journey, from meaningful lessons to a joyful and memorable celebration. Family Information Family Name* Address* Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Home Area Code Phone Number Father's Name* Father's Hebrew Name If available Father's Email* Father's Cell* Area Code Phone Number Father's Religion* Jewish by BirthJewish by ChoiceOther Father's Parents Religion Father's Father Jewish by BirthFather's Father Jewish by ChoiceFather's Mother Jewish by BirthFather's Mother Jewish by Choice Mother's Name* Mother's Hebrew Name If available Mother's Email* Mother's Cell* Area Code Phone Number Mother's Religion* Jewish by BirthJewish by ChoiceOther Mother's Parents Religion Mother's Father Jewish by BirthMother's Father Jewish by ChoiceMother's Mother Jewish by BirthMother's Mother Jewish by Choice Parents' Marital Status* Does someone other than the parent(s) care for your child(ren)? If yes, please give name and phone number Child's Information I would like assistance preparing for my child's * Bar MitzvahBat Mitzvah Name* Hebrew Name If available Birth Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of birth* School Attending* Grade Entering* KindergartenFirstSecondThirdFourthFifthSixthSeventh Placement in Family* Allergies or medications* Does your child have any medical, developmental or behavioral issue that we should know about? Describe:* Bar Mitzvah Info I would like assistance procuring a pair of Tefillin for my son YesNo I would like my son to prepare for his Bar Mitzvah, with lesssons for general Jewish knowledge YesNo I would like my son to learn to read Hebrew YesNoAlready Reads Hebrew I would like my son to learn to read his Torah Portion YesNo Bat Mitzvah Info I would like my daughter to prepare for her Bat Mitzvah, with lesssons for general Jewish knowledge YesNo I would like my daughter to learn to read Hebrew YesNoAlready Reads Hebrew Agreement We do not have a set fee for Bar/Bat Mitzvah lessons or celebration facilitation. We work together with each family to create a mutually agreed-upon arrangement for the lessons and any celebration planning or support services. * I understand that my submission will be reviewed upon receipt and that participation in the Bar/Bat Mitzvah program and lessons will be confirmed in writing. Upon acceptance, I agree to work together to establish mutually agreed-upon fees for the lessons and celebration arrangements. Father's Initials* Mother's Initial* Register Should be Empty: This page uses TLS encryption to keep your data secure.
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