2025-26 THE B-MITZVAH EXPERIENCE REGISTRATION FORM

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

2025-26 THE B-MITZVAH EXPERIENCE REGISTRATION FORM

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

STUDENT INFORMATION

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

If student wishes, share pronouns here

Answer required for "If student wishes, share pronouns here"

Date of Birth*

Answer required for "Date of Birth"

Grade as of September 2025*

Answer required for "Grade as of September 2025"

Student Phone

Number Required

Student Email

Answer required for "Student Email"

Student School*

Answer required for "Student School"

Synagogue, if applicable

Answer required for "Synagogue, if applicable"

PARENTS INFORMATION

Parent 1 First Name*

Answer required for "Parent 1 First Name"

Parent 1 Last Name*

Answer required for "Parent 1 Last Name"

Parent 2 First Name*

Answer required for "Parent 2 First Name"

Parent 2 Last Name*

Answer required for "Parent 2 Last Name"

Parent 1 Phone*

Number Required

Parents 2 Phone*

Number Required

Parent 1 Email*

Answer required for "Parent 1 Email"

Parents 2 Email*

Answer required for "Parents 2 Email"

Address*

Answer required for "Address"

City*

Answer required for "City"

State*

Answer required for "State"

Zip Code*

Answer required for "Zip Code"

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

Answer required for "In Case of Emergency, Person to Contact (If Not Parents)"

PARENT OR GUARDIAN SIGNATURE

Parent or Guardian, Print Your Name and Date*

Signature Required

AFTER REGISTRATION, YOU WILL BE REDIRECTED TO THE PAYMENT FORM

THANKS IN ADVANCE

THE @AKIVA TEAM

Please fix the highlighted areas below before submitting.

2025-26 THE B-MITZVAH EXPERIENCE REGISTRATION FORM