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

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:

$125.00 for 2011-12

$150.00 for 2012-13 

Billing Information:  
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Name on Card:
Card Number: Expiry: