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<span style="font-family: 'Trebuchet MS'; font-size: 16px;">
<strong>
<span style="color: rgb(255, 255, 255);">Student</span><span style="color: rgb(255, 255, 255);"> Information</span></strong></span></td>
</tr>
</tbody>
</table>
<p>
<span style="font-family: 'trebuchet ms'; font-size: 14px;" class="normal"><input type="text" value="Last Name" name="Last Name" required="true" tabindex="1"> <input type="text" value="First Name" name="First Name" required="true" tabindex="2"> <input type="text" value="Hebrew Name" name="Hebrew Name" tabindex="3"></span></p>
<p>
<span style="font-family: 'trebuchet ms'; font-size: 14px;"><input type="text" value="Date of Birth" name="Date of Birth" required="true" tabindex="4"> <input type="text" value="Age" name="Age" style="width: 68px; height: 22px" required="true" size="8" tabindex="5">    </span></p>
<p>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;">What school does your child attend?  <input type="text" name="School Name" required="true" tabindex="8">  Grade entering:  <input type="text" name="Grade" style="width: 64px; height: 22px" required="true" size="8" tabindex="9"></span></p>
<p>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;">Is the natural mother of the child Jewish?  <input type="radio" value="Yes" name="jewish" tabindex="10">Yes  <input type="radio" value="no" name="conversions" tabindex="10">No</span></p>
<p>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;">Were there any conversions or adoptions in your family?  <input type="radio" value="yes" name="conversions" tabindex="11">Yes  <input type="radio" value="no" name="Conversions" tabindex="11">No</span></p>
<p>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;">If yes, please describe:</span></p>
<p>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;"><textarea name="Conversions" style="width: 656px; height: 62px" required="false" cols="73" rows="3" tabindex="12"></textarea>   </span></p>
<table width="100%" cellspacing="0" cellpadding="2" border="1" bgcolor="#333333" style="border-collapse: collapse; font-family:" dir="ltr">
<tbody>
<tr>
<td style="text-align: center;">
<span style="font-family: 'Trebuchet MS'; font-size: 16px;">
<strong>
<span style="color: rgb(255, 255, 255);">Parent Information</span></strong></span></td>
</tr>
</tbody>
</table>
<p>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;"><input type="text" value="Father's Name" name="Fathers Name" required="true" tabindex="14"> <input type="text" value="Home Phone" name="Home Phone" required="false" tabindex="15"> <input type="text" value="Work Phone" name="Work Phone" required="false" tabindex="16"></span></p>
<p>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;"><input type="text" value="Cell Phone" name="Cell Phone" tabindex="17" required="false"> <input type="text" value="Email" name="Fathers Email" tabindex="18" required="true"> <input type="text" value="Occupation" name="Fathers Occupation" tabindex="19"></span></p>
<p>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;">
<input type="text" value="Address" name="Fathers Address" style="width: 474px; height: 22px" required="true" size="61" tabindex="20"></span></p>
<p>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;"><input type="text" value="City" name="Father City" required="true" tabindex="21"> <input type="text" value="MA" name="State" style="width: 26px; height: 22px" required="true" size="3" tabindex="22"> <input type="text" value="Zip" name="Father zip" required="false" tabindex="23"></span></p>
<p>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;"><input type="text" value="Mother's Name" name="Mothers Name" required="true" tabindex="24"> <input type="text" value="Home Phone" name="Mothers Home Phone" required="false" tabindex="25"> <input type="text" value="Work Phone" name="Mothers Work Phone" required="false" tabindex="26"></span></p>
<p>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;"><input type="text" value="Cell Phone" name="Mothers Cell Phone" tabindex="27" required="false"> <input type="text" value="Email" name="x_email" required="true" tabindex="28"> <input type="text" value="Occupation" name="Mothers Occupation" tabindex="29" required="false"></span></p>
<p>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;">
<input type="text" value="Address (if different than above)" name="Mothers Address" style="width: 475px; height: 22px" required="false" size="61" tabindex="30"></span></p>
<p>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;"><input type="text" value="City" name="Mothers City" tabindex="31"> <input type="text" name="State" value="MA" style="width: 34px; height: 22px" required="false" size="4" tabindex="32"> <input type="text" value="Zip" name="Mothers Zip" tabindex="33"></span></p>
<p> </p>
<p>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;"> I heard about BMW - Bar Mitzvah Woodworking from: <input type="text" name="Heard from" style="width: 225px; height: 22px" size="29" tabindex="1" required="false"></span></p>
<p>
<span style="font-family: 'Trebuchet MS';"> </span></p>
<table width="100%" cellspacing="0" cellpadding="2" border="1" bgcolor="#333333" style="border-collapse: collapse; font-family:" dir="ltr">
<tbody>
<tr>
<td style="text-align: center;">
<span style="color: rgb(255, 255, 255); font-family: 'Trebuchet MS'; font-size: 16px;">
<strong>Bar Mitzvah Club Tuition</strong></span></td>
</tr>
</tbody>
</table>
<p style="text-align: left;">The tuition for "BMW" is $125, (includes supplies and registration fee). A minimum installment of $50 is required before participating.</p>
<p align="left">
<span style="font-family: 'Trebuchet MS'; font-size: 14px;">
<em>Your FULL name here: <input type="text" name="Full Name" style="width: 231px; height: 22px" required="true" size="29" tabindex="60"></em></span></p>
<p style="text-align: left"><span style="font-family: 'Trebuchet MS'; font-size: 12px;">
<em>
<strong>This form is secure and encrypted <br>
</strong></em></span><span style="font-family: 'Trebuchet MS';">Visa<input type="radio" value="Visa" name="Credit Card type" tabindex="6">     Mastercard <input type="radio" value="Mastercard" name="Credit Card type" tabindex="6">    American Express <input type="radio" value="American Express" name="Credit Card type" tabindex="8">    Discover <input type="radio" value="Discover" name="Credit Card type" tabindex="9">
<br>
</span><a href="https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&amp;hosted_button_id=KYTDUZ8LFYCX6" target="_blank">
<span style="font-family: 'Trebuchet MS'; font-size: 14px;">
<img border="0" src="https://www.mychabad.org/media/images/265/FTLZ2656712.jpg" alt="paypal.jpg"></span></a><span style="font-family: 'Trebuchet MS'; font-size: 14px;"><br>
            Credit Card number: <input type="text" name="x_card_num" required="false" size="38" tabindex="10">
<br>
            Expiration date:  (MM/YYYY)    <input type="text" name="x_exp_date" required="false" size="10" tabindex="11">  <br>
            CVV Security Code:  <input type="text" name="cvv code" required="false" size="4" tabindex="12"></span>
<a href="https://www.mychabad.org/admin/Publishing/&amp;DocType=Form#" onclick_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt="%20onclick_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt%3D%22%2520onclick_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt%253D%2522%252520onclick_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt%25253D%252522%25252520onclick_fckprotectedatt_fckprotectedatt_fckprotectedatt_fckprotectedatt%2525253D%25252522%2525252520onclick_fckprotectedatt_fckprotectedatt_fckprotectedatt%252525253D%2525252522%252525252520onclick_fckprotectedatt_fckprotectedatt%25252525253D%252525252522%25252525252520onclick_fckprotectedatt%2525252525253D%25252525252522%2525252525252520onclick%252525252525253D%2525252525252522window.open('%252525252525252Ftools%252525252525252Fdonate%252525252525252FCVVInfo.htm'%252525252525252C'CVVInfo'%252525252525252C'width%252525252525253D440%252525252525252Cheight%252525252525253D480%252525252525252Cresizable%252525252525253Dno%252525252525252Cstatus%252525252525253Dno%252525252525252Cscrollbars%252525252525253Dyes')%252525252525253B%2525252525252520return%2525252525252520false%252525252525253B%2525252525252522%25252525252522%252525252522%2525252522%25252522%252522%2522%22">
<span style="font-family: 'Trebuchet MS'; font-size: 14px;">What's This?</span></a><span style="font-family: 'Trebuchet MS'; font-size: 14px;">   <br>
            Choose $125 - full tuition, or two installments of $62.50</span><br>
<select tabindex="1" size="1" name="x_amount">
<option selected value="Amount to be charged">Amount to be charged</option>
<option value="$125">$125 - Full Season</option>
<option value="$62.50">$62.50 Installment</option>
</select></p>
<p align="center">
<em>
<strong>
<span style="font-family: 'Trebuchet MS'; font-size: 14px;"> We Look Forward to a Fun Filled and Enriching Year!</span></strong></em></p>
</div>
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