Bar/Bat Mitzvah Cotillion Registration

* Child Name 1:

* Gender:

* Secular School:

Child Name 2:

Gender:

Secular School:

* Parent Name(s):

* Phone:

* Email:

* Home Address:

Family Congregation affiliation (If applicable):

Would you be interested in serving as a chaperone for one of the four meetings?

Yes

* In consideration of the acceptance by the Temple Israel Cotillion of my/our child as a participant in the program for the 2017 season and of similar agreements by the parents of other participants, we agree to indemnify the Temple Israel Cotillion, its Directors, Officers, Employees and Agents (including all persons serving as chaperones) against loss, damages or expense resulting from any claim or suit brought against the Temple Israel Cotillion or any of said persons (1) for any injury or damage which our son or daughter may sustain in connection with attending a dance sponsored by the Temple Israel Cotillion, and (2) for injury or damage sustained by anyone else caused by the conduct of our child occurring during or after a sponsored dance. I/We have read and agree to comply with the rules of the Temple Israel Cotillion.

I/We agree to these terms.

Payment

* Please select the number of children you're registering:

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Online Fee:

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Increase the amount by 3% to cover credit card fees. Please select YES to increase your payment.

Total: