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
Bnei-Mitzvah donation/fee:

$1,800 - Regular RateWill discuss options
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 Date*
MM/DD/YYYY
Total

$0.00 USD

Payment

Credit Card Check, Cash, Venmo

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Programs

Student Information