You are on page 1of 4

2009/2010

Membership Application
THE TEMPLE BETH SHOLOM FAMILY RECORD
(This information is treated confidentially in our Temple office.)
Full Name ______________________________________________________________________________________
Title: __Mr. __Mrs. __Ms. __Dr. ___Other _________________ (Nickname)________________________
Hebrew Name ___________________________ ben/bat ________________ v ______________________________
Father’s Name Mother’s Name
Residence Address _______________________________________________________________________________
Apt. #
City and State ___________________________________________________ Zip Code _______________________
Occupation __________________________________ Name of Business ___________________________________
Business Address _________________________________________________________________________________
City State Zip
Phone Numbers:
Home _________________________________ Business ________________________________________
Cell _________________________ Email or Fax _________________________________________________
Date you moved to Las Vegas ________________________ from _________________________________________
City State
Other Congregational affiliation _______________________ in ___________________________________________
City State
Date of birth _________ _________ _________ Place of birth ___________________________________________
Month Day Year City State
__Married __ Single ___ Separated ___ Widow ___Widower Anniversary________/ ______/_______
Month Day Year
I was raised:___ Orthodox; ___ Conservative;___ Reconstructionist; ___Reform; ___Non Practicing; ___Not Jewish
Did you convert to Judaism? ___ Yes; ____ No. Conversion Date ________________ Place __________________
City State

Rabbi who coordinated the conversion process: _________________________________________________________


Membership in Jewish Organizations _________________________________________________________________
Areas of interest in Temple activities: ___Men’s Club ___Women’s League ___Religious School ___Preschool
___Adult Education ___ Music Programming ___Committee, which Area(s) ______________________
List name and relationship to any member (s) of the Temple _______________________________________________
Spouse’s Name ___________________________________ Maiden Name ( if applicable) ______________________
Title: __Mr. __Mrs. __Ms. __Dr. ___Other _________________ (Nickname)________________________
Hebrew Name ___________________________ ben/bat ________________ v ______________________________
Father’s Name Mother’s Name
Date of birth _________ _________ _________ Place of birth ___________________________________________
Month Day Year City State

Cell _________________________ Email or Fax _________________________________________________


Occupation __________________________________ Name of Business ___________________________________
Business Address _________________________________________________________________________________
City State Zip
I was raised:___ Orthodox; ___ Conservative;___ Reconstructionist; ___Reform; ___Non Practicing; ___Not Jewish
Did you convert to Judaism? ___ Yes; ____ No. Conversion Date ________________ Place __________________
City State
Rabbi who coordinated the conversion process: _________________________________________________________
Membership in Jewish Organizations _________________________________________________________________
UNMARRIED CHILDREN IN HOUSEHOLD
Grade # of Yrs. Year of
English Name Last Name Hebrew Name Gender Birth Date In Attended Bar/Bat
(if different) School Hebrew Mitzvah
School

___ The child does not reside with me. The child’s address is _______________________________________________________
For school mailings to be sent to both parents, please list both parent’s name and address information
_________________________________________________________________________________________________________

Is the child (children) Jewish by birth? _______ If not, please explain (We consider a child Jewish when the mother was Jewish
At time of child’s birth or if the child converted to Judaism.)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

MARRIED CHILDREN or CHILDREN LIVING AWAY FROM HOME


We would like to stay in touch with our extended Temple Beth Sholom family to remind them of Holy Days and Observances.

Name ___________________________________________ Educational Institute (if applicable) ________________________


Home or Institute Address ___________________________________________________________________________________
City State Zip
Field (s) of Study (if applicable) ______________________________________________________________________________
Telephone ________________________________ Fax _____________________ Email ___________________________
Name ___________________________________________ Educational Institute (if applicable) ________________________
Home or Institute Address ___________________________________________________________________________________
City State Zip
Field (s) of Study (if applicable) ______________________________________________________________________________
Telephone ________________________________ Fax _____________________ Email ___________________________

YAHRZEIT INFORMATION
Name of Deceased ____________________________________ Relationship ___________________________________

Member to be notified _________________________________ Date of Passing ________________________________

Name of Deceased ____________________________________ Relationship ___________________________________

Member to be notified _________________________________ Date of Passing ________________________________

Name of Deceased ____________________________________ Relationship ___________________________________

Member to be notified _________________________________ Date of Passing ________________________________


TEMPLE
TEMPLE BETH
BETH SHOLOM
SHOLOM 2008/2009
2009/2010 DUES
DUES SCHEDULE
SCHEDULE

United Synagogue of America affiliation dues and Ticket(s) for Seating in the
Member’s Section for Rosh Hashanah and Yom Kippur are included.

Family Membership Dues Categories are determined


by the age of the older spouse at the time of application.

Please check the Membership Category Building Fund Assessment Number of HHD
that applies to your family situation (Payable over 5 years) Tickets Included

Family (30+ years of age)………………...……$1,560


$1,660 per
per year……………………….$2,500
year 2

$1,450 per
Senior Family (65+ years of age)………… …$1,350 peryear………………………..$2,150
year 2

$ 730
Starting Family (25-29 years of age)……….…..$ 830 per
peryear………………………..$1,175
year 2
$1,320per
Single (30+ years of age)………………...……$1,220 peryear………………………...$2,025
year 1

$1,150 per
Senior Single (65+ years of age)…………….…$1,050 per year………….……………..$1,750
year 1

$ 650
Single (25-29 years of age)……………….……$ 750per
peryear……………..………..…$1,075
year 1

Under 25 years of age (single or married)…………..No Charge……… ….………Not applicable 1

Please note that members are required to pay at least 1/2 of the Annual Membership Dues to receive courtesy seating in the member
section for the High Holy Days services. Information is available from the Temple office regarding the costs for additional High Holy
Day tickets. The membership year runs from July 1 through June 30 of each year.

Security Fee
Members of Temple Beth Sholom help to defray the cost of security through a Security Fee. The fees
fees for
for the
2009/2010 areyear
2008/2009 $125are $100
for members who do not have children in the preschool or Schechter schools and $150 for households who do have children in one of
these schools.

METHOD OF PAYMENT:

Credit Card Payments: You may pay by Visa or MasterCard. If you pay in full there will be no additional charge. If you
choose to pay by credit card in installments, a 3% fee will be charged.

____ Payment in full is enclosed.

____ Partial payment is enclosed in the amount of $_________________ (check or money order)

____ Please charge my credit card in the amount of $________________ Charge to my: ____Visa; ____ MasterCard

Card Number___________________________________________ Expiration Date_____________________

Card Issued to __________________________________________ Signature__________________________

___________________________________________________ __________________________________
(Applicant’s signature) (Date)

___________________________________________________ __________________________________
(Applicant’s signature) (Date)

Were you recommended by another Temple member? If so, whom? ___________________________________

Please return this Membership Application to the


Temple Beth Sholom office located at
10700 Havenwood Lane, Las Vegas, Nevada 89135
For further information, please call the office at (702) 804-1333