"*" indicates required fields Step 1 of 2 50% Member Information - #1TitleTitleDr.Mr.Mrs.Ms.MissFirst Name & Initial **Last Name ***Kohen *Levi *Israelite *Non-Jewish *Date of Birth* Month Day Year Marital Status **Marital Status *SingleMarriedWidowedSeparatedDivorcedWedding Anniversary Month Day Year Address * Street Address Address Line 2 City State *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone NumberCell Phone NumberEmail Address **Job Title/OccupationBusiness NameBusiness AddressBusiness Phone NumberHave You Chanted a Haftorah?Have You Chanted a Haftorah?YesNoIf yes, date last read Month Day Year Have You Read From the Torah?Have You Read From the Torah?YesNoIf yes, date last read Month Day Year Hebrew Name (may be transliterated)Ben/Bat (Son of -or- Daughter of) (Father’s name) (Mother’s name)Do you wish to add your spouse as a member?select one...YesNoMember Information - #2TitleTitleDr.Mr.Mrs.Ms.MissFirst Name & Initial **Last Name ***Kohen *Levi *Israelite *Non-Jewish *Date of Birth* Month Day Year Marital Status **Marital Status *SingleMarriedWidowedSeparatedDivorcedWedding Anniversary Month Day Year Address * Street Address Address Line 2 City State *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone NumberCell Phone NumberEmail Address **Job Title/OccupationBusiness NameBusiness AddressBusiness Phone NumberHave You Chanted a Haftorah?Have You Chanted a Haftorah?YesNoIf yes, date last read Month Day Year Have You Read From the Torah?Have You Read From the Torah?YesNoIf yes, date last read Month Day Year Hebrew Name (may be transliterated)Ben/Bat (Son of -or- Daughter of) (Father’s name) (Mother’s name)This field is hidden when viewing the formHow many dependent children do you have?*please select one...none1234Dependent Child - #1Name First Last Date of Birth* Month Day Year Hebrew NameAddressCurrent GradeDependent Child - #2Name First Last Date of Birth* Month Day Year Hebrew NameAddressCurrent GradeDependent Child - #3Name First Last Date of Birth* Month Day Year Hebrew NameAddressCurrent GradeDependent Child - #4Name First Last Date of Birth* Month Day Year Hebrew NameAddressCurrent GradeThis field is hidden when viewing the formDo you have any Yahrzeit Record's would you like to enter, if so how many?select one...none1234Yahrzeit Record - #1Name of DeceasedHebrew Name of DeceasedWhich Member was the Deceased Related to?Deceased Relationship to MemberEnglish Date of Death* Month Day Year Hebrew Date of Death Month Day Year Yahrzeit Record - #2Name of DeceasedHebrew Name of DeceasedWhich Member was the Deceased Related to?Deceased Relationship to MemberEnglish Date of Death* Month Day Year Hebrew Date of Death Month Day Year Yahrzeit Record - #3Name of DeceasedHebrew Name of DeceasedWhich Member was the Deceased Related to?Deceased Relationship to MemberEnglish Date of Death* Month Day Year Hebrew Date of Death Month Day Year Yahrzeit Record - #4Name of DeceasedHebrew Name of DeceasedWhich Member was the Deceased Related to?Deceased Relationship to MemberEnglish Date of Death Month Day Year Hebrew Date of Death Month Day Year Date* Month Day Year Signature* Membership Choices Household Membership: Two Adults and all children under age 18 living at the same address. Household membership includes two tickets for admission to High Holiday services. Children under age 18 do not require High Holiday tickets. If both parents are 35 or younger, membership is free for the first year. Dues: $745.00 Individual Household or Single Parent Membership: Single parent household including child(ren) under age 18 living at the same address, or an adult who does not have any child(ren) under 18 living at the same address. The Individual Family or Single Parent membership includes one ticket for admission to High Holiday services. Children under age 18 do not require High Holiday tickets. If parent or individual is 35 or younger, membership is free for the first year. Dues: $545.00 Associate Membership: Adults who are summer residents and do not wish to attend High Holiday services. Membership does not include High Holiday tickets. Dues: $300 Student Membership: Adults who are under age 30 and are students. Membership includes one ticket for admission to High Holiday services. Dues: FreePlease select the appropriate membership from above: Household Membership: Individual Household or Single Parent Membership: Associate Membership: Student Membership or Under 35: Total Once you click submit, you will need to finalize payment with our processor, you will be forwarded upon submitting. Please remember this amount.
