BMC-Logo-200.jpgChabad of the Maritimes  
Bat Mitzvah Club 
1171 Waterloo Street, Halifax, NS B3H 3L6 
Phone: 902.422.4222 Fax: 902.406.7770 
Email: ch[email protected]

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: 
Emergency Contact Name: Tel: 
MSI #:  
Please list any allergies or health concerns: 
My hobbies, talents and interests: 
Cost:  
$200.00 $200.00
Billing Information:  
Cash   Cheque Visa  Master Card
Name on Card: 
 Card Number:   Expiry:   
Please indicate which day you would prefer: Sunday Afternoon      Weekday Evening