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.)

Member Information

Member - Name*

Prefix First Last

Member - Email*

Member - Cell Phone*

Member - Date of Birth*

Member - Hebrew Name*

Member - Father's Hebrew Name*

Member- Mother's Hebrew Name*

Spouse - Name

Prefix First Last

Spouse - Email

Spouse - Cell Phone

Spouse - Date of Birth

Spouse - Hebrew Name

Spouse - Father's Hebrew Name

Spouse - Mother's Hebrew Name

Home Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Do you have a Northern address?

Yes

Northern Address

Street Address Address Line 2 City State ZIP Code

Northern Home Phone

Have you undergone conversion to Judaism?*

Yes

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

Bar Mitzvah Sedrah

Are you a...

Cohen

Levi

Yisrael

Business Name & Address*

Business Phone*

Children's Profiles

Number of children

(if applicable)

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

Previous Synagogues*

Synagogue Name

Synagogue City, State

Offices Held

Committees

Member #1 - Volunteer Interests

Please let us know if you are interested in volunteering on one or more of the following committees:

Spouse - Volunteer Interests

Please let us know if you are interested in volunteering on one or more of the following committees:

Yahrzeit Information

Name (English)

Name (Hebrew)

Date of Death (English)

Date of Death (Hebrew)

Relationship to Member

Member/Family Photo*

By uploading, you grant YIH permission to use photos in communications, including but not limited to the monthly bulletin, website, and promotional materials.

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

Our community would like to know about you!*

Please include a couple of lines about you that we can include in our publications to welcome you. You can include where you moved from, where you work or attend school, and any interesting information about you/your family.

Signature of Applicant*

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