Bar/Bat Mitzvah Registration

Please contact Rabbi Shaya Gopin to set up a meeting before filling out this form.

Rabbi Shaya Gopin
[email protected]
(860) 232-8556
Student Information
Student's Name*
First Name Last Name
Hebrew Name
Birth Date*

Month Day Year
Does you child read basic Hebrew?*

YesNo
If Yes:

GoodFairPoor
Is the natural mother and maternal grandmother of the child Jewish?

YesNo
Were there any conversions or adoptions in your family?

YesNo
If yes, please describe:
Additional comments:
Parent Information
Father's Name
First Name Last Name
Father's Phone Number
Father's E-mail
Father's Occupation
Mother's Name
First Name Last Name
Mother's Phone Number
Mother's E-mail
Mother's Occupation

Home Address*

Home Number
Emergency Information
Emergency Contact
Name/Phone/Relationship
Doctor
Name/Phone/Address
Allergies or other Medical Condition
Bnei-Mitzvah donation/fee:

$1,800 - Regular Rate
As the parent(s) or legal guardian of the above child, I authorize any adult acting on behalf of Chabad to hospitalize or secure treatment for my child. I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Chabad personnel will try, but are not required, to communicate with me prior to such treatment.

As per the Bar Mitzvah handbook, I/we agree to ensure that all food served at events related to the Bar-Mitzvah will be certified kosher.
I Agree to the terms and conditions above.
Parent/Guardian Signature
Initials Date
Upload your electronic signature:
(Optional)
Total

$0.00 USD

Payment

Credit Card Check, Cash, Venmo

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Programs

Student Information