B-Mitzvah Registration/Emergency Info

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REGISTRATION INFORMATION

Student's Last Name

Student's First Name

Student's Birthdate

Name of School

Current Grade

Student's Primary Address

City

Zip Code

* Parent #1 Last Name

First Name

Parent E-mail

Home Phone

Cell Phone

Parent #2 Last Name

First Name

Parent Email

Home Phone

Cell Phone

Emergeny Contact Last Name

Emergency Contact First Name

Emergency Contact's Relationship to the Child

Emergency Contact Address

Emergency Contact Cell Phone Number

PAYMENT INFORMATION

The cost of our B'nei-Mitzvah program is $4000. This includes all private learning sessions with Rabbi Diane and/or another tutor as well as any extra lessons or meetings with family in preparation for the final ceremony. If the family is part of our Partner program, this fee also includes Rabbi Diane officiating the service and bringing our sound system if needed. If the family is not part of our Partner program (which is a donation of $100 per month or $1200 per year), there is an extra fee of $1100. So, please consider becoming one of our Partners. If you attend High Holy Day services, one of our classes, our seder, or any other events, your partnership will save you money on those events as well.

Please contact our Treasurer if you would need to make other financial arrangements. We won't ever turn a student away because of finances!

Payment

If you are becoming a Partner Family, please enter $4000.00 here. If not, please enter $5100.00. The cost can be divided over many payments if you wish as long as it is paid in full by the time of the Bar/Bat-Mitzvah.

Annual Donation Amount

You may set up your annual/monthly donation here to become one of our Partner Families. We request an annual family donation of $1200 ($100 per month) to take part in this program.

MEDICAL INFORMATION

Child's Physician

Physician's Phone Number

Child's known allergies

Any known medical conditions you wish for the teaching staff to be aware of

Medical authorization

Please check the box to authorize the Cool Shul educators or any adult volunteers to make available medical care if such care is indicated. It is understood that a conscientious effort will be made to notify me, my spouse, or designated emergency contact before such action is taken. It is further understood that every effort will be made to contact my child's physician prior to any treatment. I give permission for my child to receive proper medical treatment by any doctor, nurse, paramedic or hospital staff licensed by the State of California.

Sun, May 28 2023 8 Sivan 5783