membership_promo.jpg

SECTION I | Your Information
Last Name
First Name
Hebrew Name
Father's Hebrew Name
Mother's Hebrew Name
Occupation
Birth Date [MM / DD / YYYY]
Day
Night		 Jewish by
Birth Mother Jewish at birth Maternal Grandmother Jewish at birth		 I am a
Cohen Levi Israel
Cell Phone
Work Phone
Email
SECTION II | Spouse's Information
Last Name
First Name
Hebrew Name
Father's Hebrew Name Mother's Hebrew Name Occupation
Birth Date [MM / DD / YYYY]
Day
Night		 Jewish by
Birth Mother Jewish at birth Maternal Grandmother Jewish at birth		 I am a
Cohen Levi Israel
Cell Phone
Work Phone
Email
SECTION III | Personal Information
Address
City/State/Zip
Home Phone
Marital Status: Single Never been Married Married Divorced Widowed
Anniversary Date [MM / DD / YYYY]
Divorce Date
(if applicable) [MM / DD / YYYY]
If divorced, do you have a Jewish Get?
Yes No		 Who was Get administered by?
Widowed Date (if applicable) [MM / DD / YYYY]
SECTION IV | Children
Child 1 Male Female Name
Hebrew Name
Birth Date [MM / DD / YYYY]
/ / 		Day Night School
Child 2 Male Female Name
Hebrew Name
Birth Date [MM / DD / YYYY]
/ / 		Day Night School
Child 3 Male Female Name
Hebrew Name
Birth Date [MM / DD / YYYY]
/ / 		Day Night School
Child 4 Male Female Name
Hebrew Name
Birth Date [MM / DD / YYYY]
/ / 		Day Night School
Child 5 Male Female Name
Hebrew Name
Birth Date [MM / DD / YYYY]
/ / 		Day Night School
Child 6 Male Female Name
Hebrew Name
Birth Date [MM / DD / YYYY]
/ / 		Day Night School
Child 7 Male Female Name
Hebrew Name
Birth Date [MM / DD / YYYY]
/ / 		Day Night School
Child 8 Male Female Name
Hebrew Name
Birth Date [MM / DD / YYYY]
/ / 		Day Night School
  Are any children adopted?
Yes No		 If yes, give details, including any conversion info:
SECTION V | Yahrtzeits
Name
[English / Hebrew / Father's Hebrew / Last]		 Date of Passing [MM / DD / YYYY]

Day
Night		 Relationship
Name

[English / Hebrew / Father's Hebrew / Last]		 Date of Passing [MM / DD / YYYY]
Day
Night		 Relationship
Name

[English / Hebrew / Father's Hebrew / Last]		 Date of Passing [MM / DD / YYYY]
Day
Night		 Relationship
Name

[English / Hebrew / Father's Hebrew / Last]		 Date of Passing [MM / DD / YYYY]
Day
Night		 Relationship
Name

[English / Hebrew / Father's Hebrew / Last]		 Date of Passing [MM / DD / YYYY]
Day
Night		 Relationship
Name

[English / Hebrew / Father's Hebrew / Last]		 Date of Passing [MM / DD / YYYY]
Day
Night		 Relationship
Section VI | Membership Opportunities
All Membership fees can be made in one payment or in quarterly or monthly installments
Please select the option of your choice:
Membership Annual Quarterly Monthly
Benefactor* $2400 $600 $200
*a voluntary commitment for those who wish to contribute over and beyond the membership fees 
Family $1800 $450 $150
Single Adult $1200 $300 $100
Young Family (under 35) $900 $225 $75
Young Adult (under 35) $600 $150 $50
Section VII | Programs of Interest
Girl's Club Bat Mitzvah Weekly Teen Volunteer Club
Loaves of Love Women's Lunch n Learn Dinner n Torah class
Youth Zone Mini Chefs Sunday Fundays
Jbabies Guest Lecturers Bar Mitzvah Lessons
Pre-wedding Bridal Classes Shabbat adventure kids program Community Shabbat Dinners
Holiday Programs One-on-one Learning Mezuzah Checking
Pre-marital bridal classes / Mikvah lessons  
Section IX | Payment Authorization

Payment method:
I will send a check.
One-time payment for membership option selected above. Please charge my card today.
Recurring monthly payments for membership. Please charge my card below on the 1st of every month.
Recurring quarterly payments for membership. Please charge my card below every 3 months.

Comments/Special Requests
Amount to be charged TODAY
[First recurring payment or one time amount]
$ 		Card Type
Card Number
Expiration Date
Card Security Code
I hereby certify that all information given above is true and correct and that I, and all members of my immediate family named herein, are Jewish by birth, or by conversion in accordance with Orthodox Jewish Law (Halacha).