ב"ה

Bar/Bat Mitzvah Registration

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

Rabbi Eli Rivkin
818.793.9313
[email protected]
Student information
Student's Name*
First Name Last Name
Hebrew Name
Birth Date*

Month Day Year
Does your 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
Father's First Name Last Name
Mobile Number

Area Code Phone Number
Father's E-mail
Father's Occupation
Mother's Name
First Name Last Name
Mobile Number

Area Code Phone Number
Mother's E-mail
Mother's Occupation

Home Address

Home Number

Area Code Phone Number
Emergency Infomation
Emergency Contact
Name/Phone/Relationship
Doctor
Name/Address/Phone
Allergies or other Medical Condition
Bnei-Mitzvah donation/fee:
Membership* rate: $900 | Regular rate: $1,800

50% of the fee is due when reserving your child's ceremony date.

*Minimum two year membership required. Click here to find out more about membership.
Are you part of the optional Chabad of Northridge membership program?

We are membersWe are not members
Member*

$900 Pay-in-full$450
Non Member*

$1,800 Pay-in-full$900
$0

Payment

Credit Card Paypal

Postal / Zip Code

Country

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
Should be Empty:

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