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
Date Format: MM slash DD slash YYYY
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.
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About the person celebrating his/her Bar/Bat Mitzvah: