Bar/Bat Mitzvah Student's Information 

Name: :Hebrew Name:
Address: Birthday: 
Time of Birth: Hebrew Birthday:
School:  Current Grade (2014- 15):   
Hebrew Experience:              


Parents’ Information

Mother’s Name:     Hebrew Name:
Cell Phone:  Email:     
Father’s Name:   Hebrew Name:
Cell Phone:  Email:   


Is the natural mother of the child Jewish? Yes  No
Were there any conversions or adoptions in your family? Yes  No
If yes, please explain: 
Is the Bar Mizvah boy a:Kohen   Levi   Israelite 
Date of Bar Mitzvah Service: Parshah – Haftorah:

I have read the Bar Mitzvah Parent Guide, I am prepared to comply with all of its requirements, and agree to allow my sons picture be posted on the Chabad website.