Bar Mitzvah Registration

Bar Mitzvah Club
Registration Form
Every Sunday from 10:00 AM to 12:30 PM
at the Silverstein Hebrew Academy, 117 Cutter Mill Road, Great Neck NY
Boys Name*
First Name Last Name
Birth Date*

Month Day Year
Grade Entering*
School Name*

Address*

Mother's Info*

Father's Info*

I hereby permit my child to participate in all activities, join in class and school trips on and beyond school properties. In case of an emergency, I herby authorize the school to have my child taken care of by a physician in any way that the situation may call for.
Cost*

$770
Total

$0.00
Terms and Conditions*

I, the undersigned agree, understand and authorize the amount shown above to be charged to my credit card for the items shown on the referenced order. I understand these charges will appear on my credit card statement under my name and I accept full financial responsibility for payment of this order.I agree payments are non-refundable and services / merchandise have been rendered / delivered to my satisfaction.
E-mail to send confirmation to*

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

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Bar Mitzvah Club