Membership Application

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Adult 1

Title (Adult 1)

Title (Adult 2)

* First Name (Adult 1)

First Name (Adult 2)

* Last Name (Adult 1)

Last Name (Adult 2)

* Gender (Adult 1)

* Gender (Adult 2)

Tribe (Adult 1)

Tribe (Adult 2)

* Marital Status (Adult 1)

Marital Status (Adult 2 if different)

* Primary Email Address (Adult 1)

Primary Email Address (Adult 2)

* Birthday (Adult 1)

Birthday (Adult 2)

Wedding Anniversary (Adult 1)

Wedding Anniversary (Adult 2 if different)

* Address Line 1 (Adult 1)

Address Line 1 (Adult 2 if different)

Address Line 2 (Adult 1)

Address Line 2 (Adult 2 if different)

* City (Adult 1)

City (Adult 2 if different)

* State (Adult 1)

State (Adult 2 if different)

* Zip (Adult 1)

Zip (Adult 2 if different)

* Home Phone (Adult 1)

Home Phone (Adult 2 if different)

* Cell Phone (Adult 1)

Cell Phone (Adult 2)

* Billing Delivery Preference

Job Title (Adult 1)

Job Title (Adult 2)

Business Name (Adult 1)

Business Name (Adult 2)

Business Phone (Adult 1)

Business Phone (Adult 2)

Out of Town Address (Adult 1)

Out of Town Address (Adult 2)

Approx. Out of Town Dates (Adult 1)

Approx. Out of Town Dates (Adult 2)

Bar/Bat Mitzvah (Adult 1)

Bar/Bat Mitzvah (Adult 2)

Parsha (Adult 1)

Parsha (Adult 2)

Languages (Adult 1)

EnglishRussianHebrewYiddish

Languages (Adult 2)

EnglishRussianHebrewYiddish

Other Languages (Adult 1)

Other Languages (Adult 2)

* Do you read Hebrew? (Adult 1)

Do you read Hebrew? (Adult 2)

* Would you like to chant Haftarah or read Torah? (Adult 1)

Would you like to chant Haftarah or read Torah? (Adult 2)

* Would you like to learn to chant Haftarah or read Torah? (Adult 1)

Would you like to learn to chant Haftarah or read Torah? (Adult 2)

Hebrew First Name (Adult 1)

Hebrew First Name (Adult 2)

Hebrew Father's Name (Adult 1)

Hebrew Father's Name (Adult 2)

Hebrew Mother's Name (Adult 1)

Hebrew Mother's Name (Adult 2)

Do you own a cemetery plot? (Adult 1)

Do you own a cemetery plot? (Adult 2)

If yes, where? (Adult 1)

If yes, where? (Adult 2)

Yahrzeit Record

Name of Deceased

Member's Relationship to Deceased

English/Hebrew Date of Death

Hebrew Name of Deceased

Name of Deceased

Member's Relationship to Deceased

English/Hebrew Date of Death

Hebrew Name of Deceased

Name of Deceased

Member's Relationship to Deceased

English/Hebrew Date of Death

Hebrew Name of Deceased

Name of Deceased

Member's Relationship to Deceased

English/Hebrew Date of Death

Hebrew Name of Deceased

Dependent Children

Name

Date of Birth

Hebrew Name

Current Grade

Name

Date of Birth

Hebrew Name

Current Grade

Name

Date of Birth

Hebrew Name

Current Grade

Name

Date of Birth

Hebrew Name

Current Grade

Adult Children

Name

Date of Birth

Hebrew Name

Address

Name

Date of Birth

Hebrew Name

Address

Name

Date of Birth

Hebrew Name

Address

Name

Date of Birth

Hebrew Name

Address

Activities of the Congregation
Please check if interested

For dues and other financial information, please call the office at (585) 473-1770.

Additional notes:

Tue, October 28 2025 6 Cheshvan 5786

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