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Last Name

Please select:

First Name

Last Name

Hebrew Name (include father’s & mother’s name)

Home Address

Email Address

Cell Phone

Home Phone

Date of Birth

Marital Status

Spouse's Last Name

Please select:

Spouse's First Name

Spouse's Hebrew Name (include father’s & mother’s name)

Spouse's Email Address

Spouse's Cell Phone

Spouse's Date of Birth

Please select:

Bar Mitzvah Parsha (if applicable)

Children’s Names, Hebrew Names, Birthdates & Bar Mitzvah Parsha if applicable

Please list any Yahrzeit Information, the relationship to the member and the Yahrzeit date

Please list other synagogue memberships or affiliations