Bat Mitzvah Registration

Parent Name*

First Name Last Name

Address*

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

Child's Full Name*

First Name Last Name

Child's Email*

Child's Cell Phone*

Hebrew Name*

First Name Last Name

Birth Date*

Month Day Year

School Attending*

Hebrew School*

Congregation*

Child* Please Choose One

Child's Biological Mother* Please Choose One

Child's Maternal Biological Grandmother* Please Choose One

Child's Father* Please Choose One

Mother*

First Name Last Name

Mother's Cell Phone*

Mother's Email*

Father*

First Name Last Name

Father's Cell Phone*

Father's Email*

Desired Service Date*

Month Day Year

Estimated # of Guests in Attendance at Service*

Please note if child has any learning disabilities or difficulties*

Additional Comments

Consent*

I understand that it is my responsibility to oversee my child’s progress and ensure that they thoroughly review the material regularly in order to successfully meet the goals of Bat Mitzvah preparation.I agree to make every effort to attend Shabbat morning services as often as possible (at least once a month) leading up to the Bat Mitzvah.I agree to make a payment of $2,500 to Chabad of Potomac Village to cover weekly 30 minute Bat Mitzvah lessons and a Bat Mitzvah service at Chabad of Potomac Village.

Payment* Your card will be manually processed based on your selection here.

I will pay $2,500 at this time with the credit card below.I agree to pay $2,500 divided in four payments starting now and concluding one month prior to the Bat Mitzvah service, to be charged to the credit card below.

Additional Donation (Optional) in ADDITION to the required fee listed above

Total

$0.00

Yes, I'd like to donate the cost of processing this transaction by adding 3%

Payment*

Credit Card Check

Postal / Zip Code

Country

Synagogue Services

Adult Education

Youth Programs

Holiday Celebrations

Online Learning

Rosh Chodesh Society