REGISTRATION

Address: (If different than billing address)

School:*
2. Parent's Information:
Mother's Name:*
First Name Last Name
Mother's Phone Number:*
Mother's E-mail:*
Father's Name:*
First Name Last Name
Father's Phone Number:*
Father's E-mail:*
Marital Status:*

MarriedWidowedDivorcedSeparated
Is mother:*

Jewish by BirthConverted
If converted, please specify Rabbinic Authorization:
Do you give permission to use photographs of your child in print materials, on our website, emails and social media?*

YesNo
Facebook/Instagram: To see pictures and updates
3. Emergency Contact Information:
Emergency Contact 1:*
First Name Last Name
Relation to Child:*
Phone Number*
Allergies / Special Health Considerations:*
Permission for Emergency Medical Treatment:*

In case of an emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital, and authorize all medical treatment as may be prescribed by the attending physician/paramedics for my child and waive my right to informed consent of treatement. This waiver applies only in the event that neither parent/guardian can be reached.
Signature:* Agreement to all terms and conditions written above.
First Name Last Name
4. Payment:
BMC Club:*

$975 (Including BMC Ceremony)
Total

$0.00

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

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