Membership Application

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Associate membership only, Name of synagogue at which you maintain a full dues paying membership:

First Member

* First Name

Middle Name

* Last Name

Gender:

Pronouns

* E-Mail Address

Full Hebrew Name, Transliterated

(Type for English letters)

Full Hebrew Name, in Hebrew (optional)

(Use pop-up keyboard for Hebrew letters)

Tribe

Birthday

Mobile Phone Number:

Title

Work Phone:

Occupation:

Bar/Bat Mitzvah Portion

(If applicable)

Conversion Date:

(If applicable)

Conversion Synagogue:

(If applicable)

Conversion Rabbi:

(If applicable)

Second Member or Non-Jewish Spouse

First Name:

Middle Name

Last Name

Gender:

Pronouns

E-Mail Address

Full Hebrew Name, Transliterated

(Type for English letters)

Full Hebrew Name, in Hebrew (optional)

(Use pop-up keyboard for Hebrew letters)

Tribe

Birthday

Mobile Phone Number:

Title

Work Phone:

Occupation:

Bar/Bat Mitzvah Portion

(If applicable)

Conversion Date:

(If applicable)

Conversion Synagogue:

(If applicable)

Conversion Rabbi:

(If applicable)

* Street Address Line 1

Street Address Line 2

* City

* State

* Zip

Home Phone

Anniversary Date

(If applicable)

CHILDREN (Transliterate all Hebrew names)

Child 1 English Name

Child 1 Hebrew Name

Tribe:

Gender:

Pronouns:

Birthdate:

Email Address:

Mobile Phone Number:

Conversion Date:

(If applicable)

Conversion Rabbi:

(If applicable)

Child 2 English Name

Child 2 Hebrew Name

Tribe:

Gender:

Pronouns:

Birthdate:

Email Address:

Mobile Phone Number:

Conversion Date:

(If applicable)

Conversion Rabbi:

(If applicable)

Child 3 English Name

Child 3 Hebrew Name

Tribe:

Gender:

Pronouns:

Birthdate:

Email Address:

Mobile Phone Number:

Conversion Date:

(If applicable)

Conversion Rabbi:

(If applicable)

Child 4 English Name

Child 4 Hebrew Name

Tribe:

Gender:

Pronouns:

Birthdate:

Email Address:

Mobile Phone Number:

Conversion Date:

(If applicable)

Conversion Rabbi:

(If applicable)

YAHRZEITS (Transliterate all Hebrew names)

English Name of Deceased

Hebrew Name of Deceased

Date of Passing (English or Hebrew)

Check if after sundown

Relationship to Mourner

Name of Mourner

English Name of Deceased

Hebrew Name of Deceased

Date of Passing (English or Hebrew)

Check if after sundown

Relationship to Mourner

Name of Mourner

English Name of Deceased

Hebrew Name of Deceased

Date of Passing (English or Hebrew)

Check if after sundown

Relationship to Mourner

Name of Mourner

English Name of Deceased

Hebrew Name of Deceased

Date of Passing (English or Hebrew)

Check if after sundown

Relationship to Mourner

Name of Mourner

Fill in any other yahrzeits here.

I am/We are interested in participating in the following areas of synagogue life:

Adult Education

Interested Member(s)

Torah/Haftarah Chanting

Interested Member(s)

Minyan/Service Participation

Interested Member(s)

Tikkun Olam (Repairing the World)

Interested Member(s)

Chevra Kadisha (Cemetery)

Interested Member(s)

Chesed Committee

Interested Member(s)

Development

Interested Member(s)

Programming

Interested Member(s)

Youth Education

Interested Member(s)

Sisterhood

Interested Member(s)

What talents, skills, interests, and hobbies do you have that you would like us to know about?

Sat, August 23 2025 29 Av 5785

Beth Sholom Synagogue ♦ 6675 Humphreys Blvd ♦ 901-683-3591 ♦ Email Us

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