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Yom Shishi, 29 Sivan 5777
Friday, June 23, 2017

Membership Application

Note: Please complete each tab and click the submit button on step 4 to complete.

A full copy of this form will be emailed to you for your records after you hit the submit button on tab 4.
You may choose to print each page singly with print button on bottom of each tab.
All information provided is private and will not be shared with anyone without your written permission.

Step 1

General Info

Member Info
Name *
Please type your full name.
Home Address *
Invalid Input
City *
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State *
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Zip Code *
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Home Phone *
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Billing Info
Is billing address the same: *
Invalid Input
If no, write billing address
Phone
Marital Status
Date
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Print

Step 2

Member Information

Adult 1
Full Name *
Hebrew Name
Nickname
Date of Birth
Gender
Occupation/Profession
E-Mail Address* *
Cell Phone
Business Name
Business Phone & ext. no.
Religious Tradition in which you were raised.
List relationship to any member of our congregation.
Current or previous Temple affiliation.
Reason for joining our congregation.

Child 1
First Name
Middle Name
Surname if different
Hebrew Name
Birthdate
Sex
If student, name of school public/private/current grade
This child will attend Bet Sefer
Bar/Bat Mitzvah Date

Child 3
First Name
Middle Name
Surname if different
Hebrew Name
Birthdate
Sex
If student, name of school public/private/current grade
This child will attend Bet Sefer
Bar/Bat Mitzvah Date
Adult 2
Full Name
Hebrew Name
Nickname
Date of Birth
Gender
Occupation/Profession
E-Mail Address
Cell Phone
Business Name
Business Phone & ext. no.
Religious Tradition in which you were raised.
List relationship to any member of our congregation.
Current or previous Temple affiliation.
Reason for joining our congregation.

Child 2
First Name
Middle Name
Surname if different
Hebrew Name
Birthdate
Sex
If student, name of school public/private/current grade
This child will attend Bet Sefer
Bar/Bat Mitzvah Date

Child 4
First Name
Middle Name
Surname if different
Hebrew Name
Birthdate
Sex
If student, name of school public/private/current grade
This child will attend Bet Sefer
Bar/Bat Mitzvah Date
Print

Step 3

Additional Info

If applicable, please list present affiliations in civic & cultural clubs, Jewish & community organizations:
Are you and/or your spouse a survivor of the Holocaust or children of survivors?
Can you and/or your spouse read or speak Hebrew?
Would you be interested in becoming a Torah reader?
Person to contact in case of emergency
Name
Phone
Relationship
Print

Step 4

Yahrzeit

Please list names and dates of those for whom you wish Yahrzeit (anniversary of death) mentioned from the bima and in the newsletter.

Yahrzeit Family Member
Name
Yahrzeit Date
Relationship to Which Member
Print in Yiskor book

Yahrzeit Family Member
Name
Yahrzeit Date
Relationship to Which Member
Print in Yiskor book

Yahrzeit Family Member
Name
Yahrzeit Date
Relationship to Which Member
Print in Yiskor book
Yahrzeit Family Member
Name
Yahrzeit Date
Relationship to Which Member
Print in Yiskor book

Yahrzeit Family Member
Name
Yahrzeit Date
Relationship to Which Member
Print in Yiskor book

Yahrzeit Family Member
Name
Yahrzeit Date
Relationship to Which Member
Print in Yiskor book

Please click here to print page #4