BMC-Logo-200.jpg Chabad V.s.L. - Bois Franc
Bat Mitzvah Club 
2500 des Nations, #200, V.s.L., QC H4R 3J9
Phone: 514.747.1199
Email:
bmc@chabadvsl.com

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: First Name: Last Name: 
Hebrew Name: Work Number:
Cell: Email:
FATHER: First Name: Last Name:
Hebrew Name: Work Number:
Cell: Email:
Emergency Contact Name: Tel:
Medicare #: Exp:

Please list any allergies or health concerns:

Please list any conversions or adoptions in the family:

My hobbies, talents and interests:
Cost:  

$125.00 for 2011-12

$150.00 for 2012-13 

 
Billing Information:  
Cash Cheque Pay Pal (Click here to pay) Visa Master Card
Name on Card:
Card Number: Expiry: