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Children & Teens

Mommy & Me Music Appreciation

Mommy & Me Registration Form
1. The Child
Child Name*
First NameLast Name
Hebrew Name
Date of Birth*
MonthDayYear
Time of Birth*To look up the Hebrew Date
HourMinutes
Child's Age*
2. The Parents
Father's Name*
First NameLast Name
Father's Cell*
Area CodePhone Number
Father's Email*
Mother's Name*
First NameLast Name
Mother's Cell*
Area CodePhone Number
Mother's Email*
Mother's Facebook Name
Mother's Instagram Name
Are both Parents Jewish?*
Please Explain, Who is Jewish?

Home Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Are Parents Currently Married?*
Any Adoptions in the Family?*
If yes Please Explain
Any Conversions in the Family?*
If yes Please Explain
Anything to be concerned?*(ex: asthma, food allergies)
Permission to Post Pictures Online*
3. Club Membership
Fee*
$20
How did you hear about us?
Social MediaFriendCall / Txt

Payment*

Credit Card Other

Postal / Zip Code

Country

I would like to receive news and updates by email
Should be Empty:

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