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                  <font color="#451c52"><strong><img alt="Bat Mitzvah Club - Chabad Merrimack Valley" border="0" src="https://w2.chabad.org/media/images/469/jUkn4694692.jpg"><br>
<br>
            Are you all caught up with the theme, the clothing and the party favors but clueless about the meaning? Do you think a Bat Mitzvah ends or begins with your party? <br>
            Join the Bat Mitzvah club and find out! <br>
</strong><br>
            Here girls learn about Judaism, meet other Jewish girls the same age and have loads of fun! Come Join the #1 new club 'For girls, run by girls, starring girls' empowering the members with responsibility and confidence. <strong>All girls ages 11-13</strong> are welcome-regardless of any additional Bat Mitzvah planning you are doing.</font>
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<span style="font-family: Tahoma;">
<span style="color: rgb(69, 28, 82);"><br>
            Club meets on the 3rd Wednesday of each month | 7:00pm - 8:30pm <br>
            at Chabad Hebrew School 10 Marwood Dr. Andover</span></span></span><span style="font-family: Tahoma;">
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<span style="color: rgb(69, 28, 82);">We look forward to a wonderful year of learning and growth.</span></span><span style="color: rgb(69, 28, 82);"> </span></span><font color="#451c52"><span class="style5 style2"><font face="Tahoma"><br>
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<font size="3">Please fill out your information below:</font></strong></font>                                                       </span>                                                 </font>
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<option value="Jun.">Jun.</option>
<option value="Jul.">Jul.</option>
<option value="Aug.">Aug.</option>
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<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
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<option value="31">31</option>
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                          <font size="2"><strong>                                                                                                         <font color="#2e1759">PARENT INFORMATION</font></strong>                                                                                        </font>
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<font face="Tahoma" size="2">City, State, Zip</font></span></td>
<td width="164" height="15" bgcolor="#fffefb">
<span style="color: rgb(104, 73, 137);"><input tabindex="21" required="true" type="text" size="5" style="width: 48px; height: 22px;" name="x_city"><input tabindex="21" required="true" type="text" size="4" style="width: 31px; height: 22px;" name="x_state"><input tabindex="21" required="true" type="text" size="7" style="width: 55px; height: 22px;" name="x_zip"><br>
<font size="1">
<font color="#000000" face="Tahoma">City          State          Zip</font>
                        </font></span></td>
</tr>
<tr>
<td width="81" height="15" bgcolor="#fffefb">
<span class="style5">
<font face="Tahoma" size="2">Home Phone</font></span></td>
<td width="156" height="15" bgcolor="#fffefb">
<input tabindex="22" required="true" type="text" name="x_phone"></td>
<td width="1" height="15" bgcolor="#fffefb"> </td>
<td width="91" height="15" bgcolor="#fffefb">
<span class="style5">
<font face="Tahoma" size="2">Email</font></span></td>
<td width="164" height="15" bgcolor="#fffefb">
<input tabindex="24" required="false" type="text" name="x_email"></td>
</tr>
<tr>
<td height="15" bgcolor="#fffefb" colspan="5">
<span class="style5">
<font face="Tahoma" size="2">Were there any conversions or adoptions in the family? <input tabindex="25" type="radio" value="yes" name="any conversions or adoptions"> Yes <input tabindex="26" type="radio" value="No" name="any conversions or adoptions"> No</font></span></td>
</tr>
<tr>
<td height="15" bgcolor="#fffefb" colspan="5">
<span class="style5"><font face="Tahoma" size="2">If yes, please explain:</font>                                                                          <textarea tabindex="27" required="false" cols="41" style="width: 376px; height: 36px;" name="explanation of conversions/adoptions"></textarea></span></td>
</tr>
</tbody>
</table>
<br>
<table width="650" dir="ltr" border="0" cellspacing="0" cellpadding="4" style="font-family: Arial; font-size: 10pt; border-collapse: collapse;">
<tbody>
<tr>
<td height="15" bgcolor="#f586b1" colspan="5">
<span class="style4">
<font color="#3e2359" face="Tahoma" size="2"><strong>EMERGENCY INFORMATION</strong></font></span></td>
</tr>
<tr>
<td width="81" height="15" bgcolor="#fffefb">
<span class="style5">
<font face="Tahoma" size="2">Emergency Contact 1</font></span></td>
<td width="156" height="15" bgcolor="#fffefb">
<input tabindex="28" required="true" type="text" name="Emergency Contact 1"></td>
<td width="1" height="15" bgcolor="#fffefb"> </td>
<td width="91" height="15" bgcolor="#fffefb">
<span class="style5">
<font face="Tahoma" size="2">Phone</font></span></td>
<td width="164" height="15" bgcolor="#fffefb">
<input tabindex="29" required="true" type="text" name="Emergency Contact 1 Phone"></td>
</tr>
<tr>
<td width="81" height="15" bgcolor="#fffefb">
<span class="style5">
<font face="Tahoma" size="2">Emergency Contact 2</font></span></td>
<td width="156" height="15" bgcolor="#fffefb">
<input tabindex="30" required="true" type="text" name="Emergency Contact 2"></td>
<td width="1" height="15" bgcolor="#fffefb"> </td>
<td width="91" height="15" bgcolor="#fffefb">
<span class="style5">
<font face="Tahoma" size="2">Phone</font></span></td>
<td width="164" height="15" bgcolor="#fffefb">
<input tabindex="31" required="true" type="text" name="Emergency Contact 2 Phone"></td>
</tr>
</tbody>
</table>
<p><br>
<span class="style5">
<font face="Tahoma" size="2">CONFIDENTIAL: Does your child have any allergies or other medical condition we should be aware of?  If yes, please describe them and indicate special precautions or care needed.  <br>
<br>
</font><textarea tabindex="32" required="false" rows="4" cols="68" name="Allergies medical conditions"></textarea><font face="Tahoma" size="2"><br>
<br>
            As the parent(s) or legal guardian of the above child, I/we authorize any adult acting on behalf of Bat Mitzvah Club to hospitalize or secure treatment for my child, I further agree to pay all charges for that care and/or treatment. It is understood that if time and circumstances reasonably permit, Bat Mitzvah Club personnel will try, but are not required, to communicate with me prior to such treatment. I hereby give permission for my child to participate in all club activities, join in club trips on and beyond Chabad properties and allow my child to be photographed while participating in Bat Mitzvah Club activities and that these pictures may be used for marketing purposes.</font></span></p>
<p align="center">
<span class="style5"><font face="Tahoma" size="2"><input tabindex="33" type="checkbox" checked value="on" name="Accept"> I Accept    <br>
<br>
            Name:</font>                                                        <input tabindex="34" required="true" type="text" name="Name acceptance">                                                      <font face="Tahoma" size="2">    Initials:</font>                                                       <input tabindex="35" required="true" type="text" name="Initials acceptance"></span></p>
<table width="650" dir="ltr" border="0" cellspacing="0" cellpadding="4" style="font-family: Arial; font-size: 10pt; border-collapse: collapse;">
<tbody>
<tr>
<td height="15" bgcolor="#9375b5" colspan="5">
<span class="style3">
<font color="#231333" face="Tahoma" size="2"><strong> PAYMENT DETAILS</strong></font></span></td>
</tr>
<tr>
<td height="15" bgcolor="#fffefb" colspan="5">
<span class="style5">
<font face="Tahoma" size="2">• Club Cost for the year 2017/2018 will be $125, which includes all supplies and materials. </font></span></td>
</tr>
<tr>
<td width="116" height="15" bgcolor="#fffefb">
<span class="style5">
<font face="Tahoma" size="2">Name on card</font></span></td>
<td width="277" height="15" bgcolor="#fffefb">
<input tabindex="37" required="true" type="text" name="name on card"></td>
<td width="30" height="15" bgcolor="#fffefb"> </td>
<td width="143" height="15" bgcolor="#fffefb">
<span class="style5">
<font face="Tahoma" size="2">Card Type</font></span></td>
<td width="291" height="15" bgcolor="#fffefb">
<span class="style5">
<select tabindex="38" style="width: 156px;" name="x_card_type">
<option selected value="Select">Select</option>
<option value="American Express">American Express</option>
<option value="Visa">Visa</option>
<option value="Mastercard">Mastercard</option>
</select></span></td>
</tr>
<tr>
<td width="116" height="15" bgcolor="#fffefb">
<span class="style5">
<font face="Tahoma" size="2">Charge Amnt.</font></span></td>
<td width="277" height="15" bgcolor="#fffefb">
<input tabindex="39" required="true" type="text" name="x_amount"></td>
<td width="30" height="15" bgcolor="#fffefb"> </td>
<td width="143" height="15" bgcolor="#fffefb">
<span class="style5">
<font face="Tahoma" size="2">Card Number</font></span></td>
<td width="291" height="15" bgcolor="#fffefb">
<input tabindex="40" required="true" type="text" name="x_card_num"></td>
</tr>
<tr>
<td width="116" height="15" bgcolor="#fffefb">
<span class="style5">
<font face="Tahoma" size="2">Exp. Date</font></span></td>
<td width="277" height="15" bgcolor="#fffefb">
<span class="style5">
<select tabindex="41" name="x_exp_month">
<option selected value="Month">Month</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select><select tabindex="42" name="x_exp_year">
<option value="Year" selected>Year</option>
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021">2021</option>
<option value="2022">2022</option>
<option value="2023">2023</option>
<option value="2024">2024</option>
<option value="2025">2025</option>
<option value="2026">2026</option>
<option value="2027">2027</option>
<option value="2028">2028</option>
<option value="2029">2029</option>
<option value="2030">2030</option>
</select></span></td>
<td width="30" height="15" bgcolor="#fffefb"> </td>
<td width="143" height="15" bgcolor="#fffefb">
<span class="style5">
<font face="Tahoma" size="2">CVV Code</font></span></td>
<td width="291" height="15" bgcolor="#fffefb">
<span style="color: rgb(104, 73, 137);">
<input tabindex="43" required="true" type="text" size="5" style="width: 45px; height: 22px;" name="x_card_code"><font color="#000000" face="Tahoma" size="1">3 digits on back of card</font></span></td>
</tr>
</tbody>
</table>
<p align="center">
<font face="Tahoma" size="2"><br>
<span class="style5">For more information please contact Faigy at 978 470 2288 or email <a href="mailto:bmc@chabadmv.com">bmc@chabadmv.com</a></span></font>
              </p>
<p align="center"> </p>
</td>
</tr>
</tbody>
</table>
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