Beth Chabad C.S.L.

Bat Mitzvah Club 5780 
6501 Ch Kildare
C.S.L. Qc H4W 0A1
Phone: 514.485.7221 Cell: 514.606.1249

Childs Last Name: First Name:
Home Address: Postal:
Tel: Fax:
Child's email:
Child's Date of Birth: Hebrew Birthday:
School presently attending:
School(s) attended in the past:
Mother's First Name: Work number:
Cell: Email:
Father's First Name: Work number:
Cell: Email:
Is the father Jewish? yes no Father is: Cohen Levi Yisrael
Is the mother Jewish? yes no Please indicate if the child is adopted: yes no
Has anyone in your family converted? yes no If yes, who
Emergency Contact Name: Tel:
Ohip #:
Please list any allergies or health concerns:
My hobbies, talents and interests:
Billing Information:  
Cash Cheque Visa Master Card
Name on Card:
Card Number: Expiry: