Membership Form

Member Information
Full Name*
First Name Last Name
Hebrew Name
Birth Date

Month Day Year
E-mail*
I would like to receive news and updates by email
Spouse Information
Full Name
First Name Last Name
Hebrew Name
Birth Date

Month Day Year
E-mail
Personal Information

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Children's Information
Child 1
First Name Last Name
Child 1 Birth Date

Month Day Year
Child 2
First Name Last Name
Child 2 Birth Date

Month Day Year
Child 3
First Name Last Name
Child 3 Birth Date

Month Day Year
Child 4
First Name Last Name
Child 4 Birth Date

Month Day Year
Membership Plan
Please choose your membership plan.
$800 Family Membership$600 Individual Membership
High Holiday Service Options & Reservation
Traditional Service from 9:00 am - 1:30 pm)Family Service from 10:00 am - 12 pm)Shofar Blowing (at 11:30 am)
Adults
Children
Yizkor Book
Our Yizkor book will be distributed on Yom Kippur, as well as on other days in the year when Yizkor is said. This book will contain Yizkor prayers and insights, as well as names of the departed for whom Yizkor is recited. You can have names of your deceased family members listed in the Yizkor book for only $20.00 per listing. Please submit names by Friday, September 16, 2022.
How many names would you like to include?
Person 1
Include persons Hebrew name and his/her fathers Hebrew name
Person 2
Include persons Hebrew name and his/her fathers Hebrew name
To submit additional names for the Yizkor book please go to the Yizkor form on the Shaloh House website.
Please reserve these Kiddushim for the following weeks:
You have the option to reserve a Shabbat Kiddush in advance @ $100.00 / kiddush (in addition to membership)
Kiddush Date 1

Month Day Year
Kiddush Date 2

Month Day Year
In Honor/ Memory of:
Other Pledges
$500 Dedicate a Mezuzah (3 remaining)$360 "Dollar-A-Day" Campaign$180 Leaf on the Tree of Life
Tree of Life Dedication Message
Total

$0.00

Payment

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Postal / Zip Code

Country

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Programs

Membership Form

Member Information

Spouse Information

Personal Information

Children's Information

Membership Plan

High Holiday Service Options & Reservation

Yizkor Book

Please reserve these Kiddushim for the following weeks:

Other Pledges

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