BAR MITZVAH PROGRAM FORM – Chabad New Zealand

Child Information

First Name *

Middle Name

Last Name *

Hebrew Name *

Hebrew Date of Birth

Date of Birth *

Day

Month

Year

School

Please List any Prior Jewish Education *

Is the natural mother of the child Jewish? *YesNo

Please Upload Proof of Jewish Identity (e.g. Ketubah, Birth Certificate etc.)

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Please Upload Certificate of Conversion

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Have there been any conversions or adoptions in the family? *YesNo

ADDITIONAL INFORMATION

Please provide any information you feel we should know about your child e.g. language, court orders, additional needs etc.

PRIMARY PARENT/GUARDIAN

Prefix

First Name *

Middle Name

Last Name *

Relation to Child: *

Email Address *

Phone (Mobile) *

Phone (Landline)

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Authorisation: *

EmergencyMedicalSign In / Out

SECONDARY PARENT/GUARDIAN

Prefix

First Name *

Middle Name

Last Name *

Relation to Child: *

Email Address *

Phone (Mobile) *

Does Address Differ From PRIMARY PARENT/GUARDIAN? *YesNo

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Authorisation: *

EmergencyMedicalSign In / Out

Please Enter Your Full Legal Name Here: *

Please Sign Here: *

If you are not able to make the donation, please contact us at: Office@chabad.nz

Donation ($500.00) *Bank TransferCredit / Debit Card

Credit / Debit Card *

Bank Information for Transfer:

Account Number:

060145036883400

YOUR DONATION IS TAX DEDUCTIBLE.

Please Upload Receipt of Donation *

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