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Agudas Achim Membership Application
Please fill out this form, as well as our
Fair Share Form
, if you wish to apply to become a member of Agudas Achim.
Date
MM slash DD slash YYYY
Adult 1
Adult 1 Information
Name
First
Last
Nickname / Preferred Name
Pronouns
Occupation
Hebrew Name
Date of Birth
MM slash DD slash YYYY
Personal Status
Single
Married
Partnered
Divorced
Widowed
Adult 2 Information
Name
First
Last
Nickname / Preferred Name
Pronouns
Occupation
Hebrew Name
Date of Birth
MM slash DD slash YYYY
Our synagogue is fully accessible. Please let us know if you require any accommodations.
Contact Information- as you'd like it to appear on synagogue mailings
Name(s)
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Adult 1 Cell
Adult 2 Cell
Adult 1 Email
Adult 2 Email
Religious Background
Adult 1 Current Religious Practice
Reform
Conservative
Orthodox
Jewish Unaffiliated
Other
Adult 1 Previous Synagogue
Adult 1 Conversion Date
MM slash DD slash YYYY
Adult 2 Current Religious Practice
Reform
Conservative
Orthodox
Jewish Unaffiliated
Other
Adult 2 Previous Synagogue
Adult 2 Conversion Date
MM slash DD slash YYYY
Minor Children's Information
Child Information
Add
Remove
Please enter full name, pronouns, Hebrew name (if known), and date of birth, as well as any allergies or accomodations that may be required in the box above. You may click the + button to add additional children.
List Which Children, If Any, Will Attend Religious School at Agudas Achim
Emergency Contact Information
Emergency Adult Contact Name
First
Last
Relationship
Contact Information
Emergency Adult Contact 2 Name
First
Last
Relationship
Contact Information
Doctor's Name
First
Last
Doctor's Phone Number
Local Hospital
Opportunity for Ritual Participation
I am a:
Kohen
Levi
Yisrael
Unknown
I am interested in:
Reading Torah
Reading Haftarah
Lighting Shabbat candles on Friday night
Leading a section of the service
Blowing shofar for the High Holidays
Hagbah and Gelilah (lifting and dressing the Torah)
Reading a prayer in English or Hebrew
Playing a musical instrument in services
Giving a D’var Torah
Photo Release
I hereby grant Agudas Achim permission to use, in perpetuity, my likeness in photographic or other form in any and all of its publications, and in any and all other media, whether now known or hereafter existing, controlled by Agudas Achim or its licensees. I hereby release Agudas Achim from any and all liability that may arise out of the use of my likeness.
Photo Release
I hereby grant Agudas Achim permission to use, in perpetuity, the likeness of my minor child(ren), in photographic or other form in any and all of its publications, and in any and all other media, whether now known or hereafter existing, controlled by Agudas Achim or its licensees. I hereby release Agudas Achim from any and all liability that may arise out of the use of such likeness(es). I hereby represent that I am the parent or legal guardian of such child(ren).
Yahrzeit Information
I would like to receive annual reminders on (leave blank if you do not want annual reminders):
The Hebrew Date
The Secular Date
Yahrzeit
Add
Remove
Please list the name, family relationship, and date of death (secular and Hebrew, if known). You may click the + button to add additional yahrzeits.
Do you have a cemetery plot, mausoleum, crypt, or niche?
Yes
No
If yes, please give the location
Talents and Interests
Select your talents / interests
Needlecrafts
Planning Social Activities
Planning Community Building Activities
Music and Song
DIY Skills
Baking and Cooking
Technology Skills
Gardening
Organizing and Archiving
Art and Art Appreciation
Greeting and Ushering at Services
Additional Interests
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