First Name
Last Name
Hebrew Name
Date of Birth
School Name
Grade
Hebrew Reading Proficiency
No Poor Fair Well
Does Your Child Speak Hebrew
No Poor Fair Well

Father's Name
Father's Occupation
Father's Cell Phone
Father's Email
Is Father Jewish?
Yes, By Birth Yes, By Conversion No
Mother's Name
Mother's Occupation
Mother's Cell Phone
Mother's Email

Is Mother Jewish?
Yes, By Birth Yes, By Conversion No

We can only perform Bar/Bat Mitzva if the natural parents and grandparents are Jewish by birth or went through an Orthodox conversion. Please contact Rabbi Slavin if you have any questions. 

 Are there any conversions in the family that you know about? if yes, please call Rabbi Slavin.


Address
City
State
Zip

Emergency Contact 1:
Name
Relationship to Child
Home Phone:
Mobile Phone
Emergency Contact 2:
Name
Relationship to Child
Home Phone:
Mobile Phone
Doctor's Information
Doctor's Name Doctor's Phone Number
Doctor's Address
Medical Insurance Company Policy Number
CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of? If yes, please describe them and indicate special precautions or care needed.