Program Participation Form

To participate in the Remember a Child program, be matched with a child Shoah victim, and receive a Scroll of Remembrance for your bar/bat mitzvah, please provide and submit the information in the form below:

Parent's Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

About the person celebrating his/her Bar/Bat Mitzvah:

Bar/Bat Mitzvah Name*

First Last

Hebrew Name*

Synagogue/Temple

Date of Bar/Bat Mitzvah

Tell us about yourself:

Is there any specific Holocaust Victim who was a member of your family or any person who you would like to remember or honor at your Bar/ Bat Mitzvah? Suggested First Name, Suggested Last Name, Suggested Country/Town of Origin

Additional Information/Remarks. Please allow a minimum of one month to research your request and prepare certificate.

Contributions for Remember a Child begin at $72. Please donate at https://genafterdc.com/remember-a-child/donations-for-remember-a-child/ and confirm your donation amount here:*