Membership Application

Type of Membership*

Family Membership

Family Membership - Young Professional / Student

Single Membership

P/T or Associate Member

(Member davens at YIH occasionally and is a Member locally elsewhere)

Snowbird

(Lives in FL part of the year. Their permanent resident for IRS income tax purposes must be in another state or their State of Florida homestead tax designations must be in another county.)

Family Profile

Member/Family Photo*

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Member or Husband - Cell Phone*

Member or Husband - Email*

Member or Husband - Date of Birth*

Member or Wife - Cell Phone

Member or Wife - Email

Member or Wife - Date of Birth

Home Phone

Northern Home Phone

(if applicable)

If yes, please elaborate and provide name of Beit Din that oversaw the conversion

Wedding Anniversary Date

(if applicable)

Bar Mitzvah Sedrah

Member or Husband - Business Name & Address*

Member or Wife - Business Name & Address

Member or Husband - Business Phone*

Member or Wife - Business Phone

Member or Husband - Hebrew Name*

Member or Wife - Hebrew Name

Member or Husband - Mother's Hebrew Name*

Member or Wife - Mother's Hebrew Name

Member or Husband - Father's Hebrew Name*

Member or Wife - Father's Hebrew Name

Children's Profiles

Number of children

Child #1 - Name

Child #1 - Hebrew Name

Child #1 - Date of Birth

Child #1 - Age

Child #1 - Bar Mitzvah Date

Child #1 - School Now Attending

Child #1 - Grade

Child #1 - College or University Now Attending

(if applicable)

Child #1 - Address at School

(if applicable)

Child #2 - Name

Child #2 - Hebrew Name

Child #2 - Date of Birth

Child #2 - Age

Child #2 - Bar Mitzvah Date

Child #2 - School Now Attending

Child #2 - Grade

Child #2 - College or University Now Attending

(if applicable)

Child #2 - Address at School

(if applicable)

Child #3 - Name

Child #3 - Hebrew Name

Child #3 - Date of Birth

Child #3 - Age

Child #3 - Bar Mitzvah Date

Child #3 - School Now Attending

Child #3 - Grade

Child #3 - College or University Now Attending

(if applicable)

Child #3 - Address at School

(if applicable)

Child #4 - Name

Child #4 - Hebrew Name

Child #4 - Date of Birth

Child #4 - Age

Child #4 - Bar Mitzvah Date

Child #4 - School Now Attending

Child #4 - Grade

Child #4 - College or University Now Attending

(if applicable)

Child #4 - Address at School

(if applicable)

Child #5 - Name

Child #5 - Hebrew Name

Child #5 - Date of Birth

Child #5 - Age

Child #5 - Bar Mitzvah Date

Child #5 - School Now Attending

Child #5 - Grade

Child #5 - College or University Now Attending

(if applicable)

Child #5 - Address at School

(if applicable)

Child #6 - Name

Child #6 - Hebrew Name

Child #6 - Date of Birth

Child #6 - Age

Child #6 - Bar Mitzvah Date

Child #6 - School Now Attending

Child #6 - Grade

Child #6 - College or University Now Attending

(if applicable)

Child #6 - Address at School

(if applicable)

Committee Volunteer Profile

Are there any special needs or accommodations anyone in your family has that you’d like the shul to be aware of?

Signature of Applicant*

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