2023-2024 My Mitzvah Registration Form - Form

TUITION
October 8, 2023 - May 19, 2024

Tuition: $3600 per student
Sibling discount: -$150
Combined ceremony discount: -$150 (two children share a ceremony)
B’nai Havurah member discount: - $1800 (intended for those families who have been members in good standing for 1 year or more prior to the start of My Mitzvah)

Note: Non-BH members’ ceremonies are led by Mitzvah Mavens Risa and Hal Aqua.
BH Members’ B’nai Mitzvah ceremonies are led by Rabbi Katie Mizrahi.

We are very flexible about payment arrangements. You may pay all at once, or spread payments out over 10 months. We accept payments by check, e-check, Visa, MasterCard, and Discover.

If the full cost of tuition presents a hardship for you, please let us know. We may be able to offer a discount.

Please check this box if you would like Laura Intfen to contact you regarding financial assistance for tuition.

Please check this box if you would like Laura Intfen to contact you regarding financial assistance for tuition.All financial arrangements are kept confidential.

Payment for non-B'nai Havurah member student(s):

First StudentSecond Student - individual ceremonySecond Student - shared ceremony with first studentWe are requesting financial assistance which is pending: One StudentWe are requesting financial assistance which is pending: Two Students/ Two CeremoniesWe are requesting financial assistance which is pending: Two Students/Same Ceremony

Payment for B'nai Havurah Member student(s):

STUDENT INFORMATION for Student 1

* Student 1 First Name:

* Student 1 Last Name:

Student 1 Preferred Pronouns

* Student 1 Email

* Student 1 Grade (Fall 2021):

* Student 1 Date of Birth:

Please provide us below with any information about Student 1 that may be helpful to us as we work with your child.

For instance, list allergies, medications, accommodations, learning challenges, and any dietary needs.

B'NAI MITZVAH DATE - STUDENT 1

If you have confirmed a B'nai Mitzvah date with Risa Aqua, please enter the date, below:

Leave this blank if you have not yet confirmed a date.

If you haven't confirmed a date, please add below your 1st, 2nd, and 3rd B'nai Mitzvah date choices. If you are not sure and wish to meet with Risa Aqua, please include that below.

STUDENT INFORMATION for Student 2

If you do not wish to register a 2nd student, please continue to the next section.

Student 2 First Name

Student 2 Last Name

Student 2 Preferred Pronoun

Student 2 Email

Student 2 Grade (Fall 2021)

Student 2 Date of Birth (MM/DD/YYYY):

Please provide us with any information about Student 2 that may be helpful to us as we work with your child

For instance, list allergies, medications, accommodations, learning challenges, and any dietary needs.

B'NAI MITZVAH DATE - STUDENT 2

If you have confirmed a B'nai Mitzvah date with Risa Aqua, please enter the date, below:

If you haven't confirmed a date, please add below your 1st, 2nd, and 3rd B'nai Mitzvah date choices. If you are not sure and wish to meet with Risa Aqua, please include that below.

PARENT AND EMERGENCY INFORMATION

Please make one selection, below.

My information has not changed since last year (skip this section)My information has changed since last year. See my changes below.I am a new parent. (Please complete the form below.)

First Name Parent 1

* Last Name Parent 1

Parent 1 Phone Number:

Parent 1 Email Address

This is the email that this application will use to send to confirm receipt of this form.

Street Address:

City:

ZIP:

First Name Parent 2

Last Name Parent 2

Parent 2 Phone Number:

Parent 2 Email Address:

Parent 2 Street Address (if different than above):

Parent 2 City:

Parent 2 ZIP:

Emergency Contact Name 1:

Emergency Contact 1 Relationship to Child(ren):

Emergency Contact 1 Phone Number:

Total tuition cost:

PARENTAL RELEASES

Please review the following electronic releases and add your name with your acceptance.

Emergency Release

By entering my name above, I hereby give permission to B’nai Havurah or its agent to hospitalize and/or secure proper treatment for my child(ren) as named in this release form in the event of an emergency.

Field Trip Release

By entering my name above, I authorize my child(ren) as named above to leave B’nai Havurah for field trips with adequate supervision and advanced notice.

Photo/Video Release

By entering my name above, I grant permission to B’nai Havurah Denver Jewish Reconstructionist Congregation (“B’nai Havurah”) and its agents and employees the unrestricted right to reproduce the photographs and video images and sound recordings of my child(ren) for marketing purposes in print, social media, presentations, and on the B’nai Havurah website. Student names will not be used without a separate, signed release.

For helpful information not included in this form, please CLICK HERE.