Family Last Name _____________________________          Membership Number (5 digits): _____

How would you like your mail addressed? _________________________________________________

Address (street, city, state, zip)___________________________________________________________

Home: Phone__________________ Fax___________________ E mail________________________________

Date of Birth (month/day/year) _____________ Sex: M___ F____

Jewish: Y___ N____        Jew by Choice: Y ___ N _______

Married:___  (Date of marriage____________)   Single___ Widowed___  Divorced___ Separated ___

Occupation____________________ Area of Expertise________________ Employer_______________________

Business: Address______________________________________________________________________________

Phone________________ Fax_________________ Email_________________________ Cell phone ___________

Hebrew Name________________________________ Kohen, Levi, Israelite_______________________________

Your Father: Name___________________________ Hebrew Name___________________ Living; Y____  N____

Address__________________________________________________________ Home Phone__________________

Your Mother: Name____________________________ Hebrew Name__________________ Living; Y____ N____

Address__________________________________________________________ Home Phone__________________

Name of deceased    Relationship    Civil Date of Death (before/after sundown)   Hebrew Date of Death

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Do you own a cemetery plot: Y___ N___ If yes, please provide name and address of cemetery:

_________________________________________________________________________________________________

Title (Miss/Ms/Mr/Dr/Other)   First Name______________________ Last Name_______________________

Date of Birth (month/day/year) _____________ Sex: M___ F____

Jewish: Y___ N____        Jew by Choice: Y ___ N _______

Married:___  (Date of marriage____________)   Single___ Widowed___  Divorced___ Separated ___

Occupation____________________ Area of Expertise________________ Employer_______________________

Business: Address______________________________________________________________________________

Phone________________ Fax_________________ Email_________________________ Cell phone ___________

Hebrew Name________________________________ Kohen, Levi, Israelite_______________________________

Your Father: Name___________________________ Hebrew Name___________________ Living; Y____  N____

Address__________________________________________________________ Home Phone__________________

Your Mother: Name____________________________ Hebrew Name__________________ Living; Y____ N____

Address__________________________________________________________ Home Phone__________________

 YAHRZEITS

Name of deceased    Relationship    Civil Date of Death (before/after sundown)   Hebrew Date of Death

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Do you own a cemetery plot: Y___ N___ If yes, please provide name and address of cemetery:

Do you keep a kosher home? Y____ N____

Please list any special skills, interests or talents you may have which might of assistance to the congregation

(carpentry, musical talent, fundraising, publicity, etc.):

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Please list any relatives who are also members of Har Shalom:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Are you a member of any other congregation? Y____ N____

If yes, please give name and address:____________________________________________________________

Previous synagogue affiliation____________________________________________________________________

CHILDREN – All ages including those no longer living at home

English Name_______________________ Hebrew Name__________________ Married Name________________

Date of birth (month/day/year)____________ Sex: M__ F__ Jewish: Y__ N__ Bar/Bat Mitzvah Date_______

Year of High School graduation______ What religious education has your child received________________

Attending Har Shalom Religious school? Y___ N____ If not, where?___________________________________

Special needs of child:___________________________________________________________________________

Current Address (If not home)____________________________________________________________________
 

English Name_______________________ Hebrew Name__________________ Married Name________________

Date of birth (month/day/year)____________ Sex: M__ F__ Jewish: Y__ N__ Bar/Bat Mitzvah Date_______

Year of High School graduation______ What religious education has your child received________________

Attending Har Shalom Religious school? Y___ N____ If not, where?___________________________________

Special needs of child:___________________________________________________________________________

Current Address (If not home)____________________________________________________________________
 

English Name_______________________ Hebrew Name__________________ Married Name________________

Date of birth (month/day/year)____________ Sex: M__ F__ Jewish: Y__ N__ Bar/Bat Mitzvah Date_______

Year of High School graduation______ What religious education has your child received________________

Attending Har Shalom Religious school? Y___ N____ If not, where?___________________________________

Special needs of child:___________________________________________________________________________

Current Address (If not home)____________________________________________________________________

Please indicate youth group(s) child/ren may be interested in by writing name(s) in appropriate spaces:

Gesher (grades K-2)____________ USY (grades 9-12)___________

Klub Kef (grades 3-5)_____________ College Outreach ____________

Kadima (grades 6-8) ____________

In order to continue to be a vibrant, active congregation, Har Shalom needs dedicated, involved members. Please circle those committees and activities that appeal to you.

I would like to participate in the following ways: (please circle)

I/we understand that, should my/our marital status change, I/we will be expected to notify the synagogue within 30 days and that my/our membership category will change for the current year.

The Building Fund is payable by members beginning at age 36. The Building Fund obligations may be deferred for military personnel for up to two years. If you choose to defer this obligation, the amount of the Building Fund will be at the rate in effect at the time you assume the obligation. There is no Building Fund assessment for members 67 or over.

I/we hereby apply for membership at Har Shalom. I/we agree that, in addition to paying the annual dues, I/we will fulfill my/our Building Fund obligations to the congregation. I/we understand that all school fees are additional. Membership is subject to the approval of the Board of Directors. The membership committee may, at its discretion, verify prior synagogue affiliation. I/we agree to comply with the provisions of the constitution and by-laws of Congregation Har Shalom (available in the synagogue office) and all present and future resolutions, rules and regulations, duly enacted by the Congregation and the Board of Directors.

 ___________________________________ Signature/Date   ________________________ Signature/Date