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2022-23 BAT/BAR MITZVAH MESIMOT PROGRAM REGISTRATION FORM

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2022-23 BAT/BAR MITZVAH MESIMOT PROGRAM REGISTRATION FORM

STUDENT INFORMATION

First Name*

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Last Name*

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Date of Birth*

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Grade as of September 2022*

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Student Phone*

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Student Email*

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Student School*

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Synagogue *

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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*

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Parents 2 Phone*

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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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Describe Any Special Learning Concerns or Considerations Which @akiva Faculty Should Be Made Aware

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PARENT OR GUARDIAN SIGNATURE

Parent or Guardian, Print Your Name and Date*

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