Membership Application 2022/2023 - Form - Congregation Beth Shalom

Welcome to Congregation Beth Shalom. We are happy you will be a part of our family.

Please fill in all applicable boxes below. We also request that you email a picture of you and/or your family to office@bethshalom.net. We will upload your picture in our system on your page.

Please advise how many adults for this application

* Date of Application

* Applicant's First Name

* Applicant Last Name

* Address

* City/State/Zip

* Home Phone / Cell Phone

* Email

* Date of Birth

Hebrew Name

bat / ben

Occupation

Employer

Business Phone

Father's English Name

Father's Hebrew Name

Mother's English Name

Mother's Hebrew Name

Advise date of your Bar/Bat Mitzvah

Tribe ( Cohen, Levi or Yisrael)

Name of former synagogue affiliation

City/State

Month/Year Left

Is Your mother Jewish by birth?

YesNo

Are you a convert or in the process of converting to Judaism?

YesNo

If yes, please forward a copy of the conversion documents to the attention of the rabbi

Spouse First Name ( if applicable)

Spouse Last Name (if applicable)

* Address

* City/State/Zip

* Home Phone / Cell Phone

* Email

* Date of Birth

* Hebrew Name

* bat / ben

Occupation

Employer

Business Phone

Father's English Name

Father's Hebrew Name

Mother's English Name

Mother's Hebrew Name

Advise the date of your Bar/Bat Mitzvah

Tribe ( Cohen, Levi or Yisrael)

Name of former synagogue affiliation

City/State

Month/Year Left

Is Your mother Jewish by birth?

YesNo

Are you a convert or in the process of converting to Judaism?

YesNo

If yes, please forward a copy of the conversion documents to the attention of the rabbi

If Married, fill in Wedding Anniversary Date (month/day/year)

Children

English Name

Hebrew Name (in English)

Birthdate

Public School Grade

Hebrew School Grade

check if child is adopted

English Name

Hebrew Name (in English)

Birthdate

Public School Grade

Hebrew School Grade

check if child is adopted

English Name

Hebrew Name (in English)

Birthdate

Public School Grade

Hebrew School Grade

check if child is adopted

English Name

Hebrew Name (in English)

Birthdate

Public School Grade

Hebrew School Grade

check if child is adopted

Yahrzeits

English Name

Hebrew Name in English

Relationship

English Date of Death

Check if died after sundown

English Name

Hebrew Name in English

Relationship

English Date of Death

Check if died after sundown

English Name

Hebrew Name in English

Relationship

English Date of Death

Check if died after sundown

English Name

Hebrew Name in English

Relationship

English Date of Death

Check if died after sundown

English Name

Hebrew Name in English

Relationship

English Date of Death

Check if died after sundown

English Name

Hebrew Name in English

Relationship

English Date of Death

Check if died after sundown

Any special interests or talents you wish to share?

Financial Commitment Form

Please read the following carefully

1. Our fiscal year runs from July 1st to June 30th. Your financial commitment will apply from now until June 30th. Member contribution and other financial obligations to the synagogue may be paid monthly, semi-annually or annually. (Please be sure to indicate your preference)

2. The Building Fund and Other Fees are detailed on the Member Contribution Schedule Fom. Also refer to the Member Contribution Schedule for definitions of membership categories and member contribution rates.

Membership Categories - please check below your category

Amud--MembershipFamily-/-Couple-Membership-ages-40-64Single Parent MembershipSenior-Couple-Membership-65--olderYoung-Family-/-Couple-Membership-under-40Individual-Membership-under-40Individual-Membership-ages-40-64Senior-Individual-Membership-age-65--olderAssociate Membership*

*Associate Membership - This requires full dues paying membership in another synagogue. Please list the name and address of Synagogue.

In order to receive High Holy Day tickets, payment of 20% of current year's dues is required. I wish to pay dues and applicable building fund:

AnnuallySemi-AnnuallyIn equal monthly paymentsOther- Contact the Executive Director to discuss.

Signatures for Agreement:

I (we) agree to pay the above stated fees (appropriate member contribution) for the year as indicated on this form

Applicant Name

Spouse Name

Date

Membership is renewed automatically each July 1st. To terminate your membership, you must submit a resignation in writing to the synagogue office. All balances due are an obligation of membership and are collectable. This form is an integral part of our accounting system. It must be signed upon application.