MEMBERSHIP INFORMATION

Names(s)______________________________________________________________________________
(Please print name(s) exactly as you wish to be listed)

Home Address___________________________________Email___________________________________

City____________________________ State_____ Zip: _________Phone____________________________

Hebrew Name___________________________________________________________________________
Father's Hebrew Name_____________________________________________________________________
Mother's Hebrew Name____________________________________________________________________

Kohen/Levi/Yisrael_______________________________________________________________________

Date of Birth____________________________________________________________________________

Occupation______________________________________________________________________________

Specialization____________________________________________________________________________

Business Name___________________________________________________________________________

Address________________________________________________________________________________

City, State, Zip___________________________________________________________________________

Business Telephone/Fax___________________________________________________________________

Jewish Background:	�Conservative		�Conservative
	�Reform		�Reform
	�Orthodox		�Orthodox
	�Reconstructionist		�Reconstructionist
	�Other_________		�Other_________
	�Jew By Choice Conversion Date_____		�Jew By Choice Conversion Date___
	As a participatory congregation we encourage members to lead or chant various parts of the service. Are there any synagogue skills you wish to share, or learn?
	I know How to:	I want to learn to:	I know How to:	I want to learn to:
	�Read from the Torah	�	�Read from the Torah	�
	�Chant a Haftorah	�	�Chant a Haftorah	�
	�Lead a Service	�	�Lead a Service	�
	�Shofar Blowing	�	�Shofar Blowing	�
	�Other___________	�	�Other________	�

CHILDREN

Name_________________________________ Hebrew Name _______________Date of Birth__________________ Name_________________________________ Hebrew Name _______________Date of Birth__________________ Name_________________________________ Hebrew Name _______________Date of Birth_________________

OTHER PERSON(S) IN HOUSEHOLD

Name______________________________________Relationship__________________________________________ Name______________________________________Relationship__________________________________________

Are you related to other Beth Israel Members? Who?__________________________________________________

YAHRZEIT RECORD:

Name:	Relationship:	English Date	Hebrew Date If Hebrew Date is not Known please indicate if before or after sunset on English date.

REMARKS

Please indicate special talents, skills, interest, willingness to serve on particular committees, etc.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Name/Community of previous Congregation__________________________________________________________

Does family have a cemetery plot? � Yes � No Location_____________________________________________

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