Congregation Shalom Membership Application

CONTACT & DEMOGRAPHIC INFORMATION

Member 1 (adult)

First Name

Last Name

Pronouns

She, her, hersHe, him, hisThey, them, theirsother

Hebrew Name (if applicable)

Birthday

Mobile Number

Member 2 (adult)

First Name

Last Name

Pronouns

She, her, hersHe, him, hisThey, them, theirsother

Hebrew Name (if applicable)

Birthday

Mobile Number

Primary Address

City

State

Zip

If married, date:

COMMUNITY CONNECTIONS

Member 1

If you are related to any members at Congregation Shalom, please list name(s) and relationship(s).

Name of congregation where you were most recently affiliated.

Member 2

If you are related to any members at Congregation Shalom, please list name(s) and relationship(s).

Name of congregation where you were most recently affiliated.

TELL US ABOUT THE ADULTS IN YOUR HOUSEHOLD

Member 1

Occupation/Profession

Special skills/talents you'd like to share

Do you chant Torah?

YesNo

Do you read Hebrew?

YesNo

Special accommodations, if needed

NoneHearing assistance deviceVisual impairmentOther

If "other" please explain

Member 2

Occupation/Profession

Special skills/talents you'd like to share

Do you chant Torah?

YesNo

Do you read Hebrew?

YesNo

Special accommodations, if needed

NoneHearing assistance deviceVisual impairmentOther

If "other" please explain

TELL US ABOUT THE CHILDREN IN YOUR HOUSEHOLD (IF APPLICABLE)

Child 1

First Name

Last Name

Hebrew Name

Date of Birth

MaleFemale

Grade (or College Level)

Name of School (or College)

Address if not living with you

Child 2

First Name

Last Name

Hebrew Name

Date of Birth

MaleFemale

Grade (or College Level)

Name of School (or College)

Address if not living with you

Child 3

First Name

Last Name

Hebrew Name

Date of Birth

MaleFemale

Grade (or College Level)

Name of School (or College)

Address if not living with you

CONGREGATION SHALOM INVOLVEMENT

We are always interested in involving our members in the life and activities of our Congregation. Please indicate any areas that are of interest to the adults in your household.

Member 1

Member 2

Is there any other information you would like to share with us?

Other information