New Membership Application

* Member 1 First Name

* Member 1 Family Name

Member 1 Nickname:

* Member 1 Hebrew Name

Member 1 Religion (if not Jewish)

* Member 1 Email Address

* Member 1 Mobile Phone Number

* Member 1 Birthday (MM/DD/YEAR)

Member 1 Employer and Profession:

Member 2 First Name

Member 2 Last Name (If different from family name)

Member 2 Nickname:

Member 2 Hebrew Name

Member 2 Religion (if not Jewish)

Member 2 Email Address

Member 2 Mobile Phone Number

Member 2 Birthday (MM/DD/YEAR)

Member 2 Employer and Profession:

* Address

* City

* State

* Zip Code

Home Phone (or which Cell # to use)

Wedding Anniversary (MM/DD/YEAR)

New Member or Returning Member

Child 1 Full Name

Child 1 Nickname:

Child 1 lives with:

Both ParentsOne ParentOther

Child 1 Birthday (MM/DD/YEAR)

Child 1 Gender:

MaleFemale

Child 1 Bar/Bat Mitzvah:

YesNo

Child 1 Date of Bar/Bat Mitzvah:

Child 1 Hebrew Name:

Child 1 School Name:

Child 1 Current Grade:

Child 2 Full Name:

Child 2 Nickname:

Child 2 lives with:

Both-ParentsOne-ParentOther

Child 2 Birthday (MM/DD/YEAR)

Child 2 Gender:

MaleFemale

Child 2 Bar/Bat Mitzvah:

YesNo

Child 2 Date of Bat/Bar Mitzvah:

Child 2 Hebrew Name:

Child 2 School Name:

Child 2 Current Grade:

Child 3 Full Name:

Child 3 Nickname:

Child lives with:

Both ParentsOne ParentOther

Child 3 Birthday (MM/DD/YEAR)

Child 3 Gender:

MaleFemale

Child 3 Bat/Bar Mitzvah:

YesNo

Child 3 Date of Bat/Bar Mitzvah:

Child 3 Hebrew Name:

Child 3 School Name:

Child 3 Current Grade:

Photo / Media Permission

YES, I give my permissionNO, I DO NOT give my permission

Any picture or portrait of a student and/or his/her family or of any part of the student and/or his/her family, and any reproductions thereof, may be used by Congregation Or Atid for such purposes as may be desired in connection with advertising, publication and/or publicity.

If NO, on media permission, please list each child's name:

Signature of Parent for OPT Out on Media

It is the custom at COA to read the names of loved ones who are no longer with us on the anniversary of their passing. You will be notified by mail or email the date your loved one's name will be read and the appropriate date to light a Yahrzeit candle. (Please notify the office if you wish you notification to be sent via email)

Do You Observe Yahrzeits?

YesNo

Member 1: Yahrzeits [Full English name of deceased; full Hebrew name of deceased; full English date of passing; Day/Evening of passing; Relationship to observer. Start each on a separate line.

Member 2: Yahrzeits [Full English name of deceased; full Hebrew name of deceased; full English date of passing; Day/Evening of passing; Relationship to observer. Start each on a separate line.

* Sustaining Share Pledge July 1st through June 30th (choose one)

Please Select OneOne PaymentQuarterly Payments (July, Oct, Jan, April)Monthly Payments

Sustaining Share Pledge Payment Selection (choose one)

Payment via credit cardPayment via check

Total Sustaining Share Pledge Amount:

Membership Declaration:
I hereby apply for membership with Congregation Or Atid and promise to abide by all the rules and regulations of the Congregation. I agree to pay the first year of my membership and thereafter by participating in the Sustaining Share Pledge program.

Signature of Member 1

Signature of Member 2

Date

For Office Use Only: Application received date

For Office Use Only: Met with Rabbi

For Office Use Only: Referring Member

For Office Use Only: Date of Board Approval

Alot Hashachar	5:36am
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