2023-24 THE B-MITZVAH EXPERIENCE REGISTRATION/PAYMENT FORM

Please complete the form below. Required fields marked with an asterisk *

2023-24 THE B-MITZVAH EXPERIENCE REGISTRATION/PAYMENT FORM

IF YOU NEED FINANCIAL AID OR A SPECIAL PAYMENT ARRANGEMENT, PLEASE CONTACT ERIN GABAY ASAP.

STUDENT INFORMATION

First Name*

Answer Required

Last Name*

Answer Required

If student wishes, share pronouns here

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Date of Birth*

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Grade as of September 2023*

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Student Phone

Number Required

Student Email

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Student School*

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Synagogue, if applicable

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PARENTS INFORMATION

Parent 1 First Name*

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Parent 1 Last Name*

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Parent 2 First Name*

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Parent 2 Last Name*

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Parent 1 Phone*

Number Required

Parents 2 Phone*

Number Required

Parent 1 Email*

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Parents 2 Email*

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Address*

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City*

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State*

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Zip Code*

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In Case of Emergency, Person to Contact (If Not Parents)*

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PARENT OR GUARDIAN SIGNATURE

Parent Signature*

Signature Required

PAYMENT

Program Payment*

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$118.00

*Payment Explanation:

$118 - Program Cost

$5.07 - CC Fee

$0.35 - Authorization Fee

Total of $123.07

*If you would like to avoid extra charges, you can send a $118 check to the Jewish Education Center Of Cleveland at 2030 South Taylor Rd. Cleveland Heights, OH 44118.

Please fix the highlighted areas below before submitting.

2023-24 THE B-MITZVAH EXPERIENCE REGISTRATION/PAYMENT FORM