Bar Mitzvah Lessons Registration

Shliach's Name

Child's First Name		Last Name
Address		City
Zip		Country
Phone		E-mail

Mother's Name		Jewish Name
Father's Name		Jewish Name
Child's Jewish Name		Birthday	M D Y
Bar Mitzvah Date or Estimate	M  D  Y

Questionnaire

Has the child ever attended Hebrew school?	Yes  No
Is the child Jewish?	Yes  No
Is the child's mother Jewish?	Yes  No
On a scale from 1-10 how would you rate the child's Hebrew reading?
Is the child's family affiliated with any Synagogues?	Yes  No