Membership Application

Membership at Cong. Sha'arei Israel and the Jewish Life Center means that you partner with us in bringing authentic Jewish values to our area. The money we raise via membership helps cover the many programs that we offer, including our synagogue services and programs, adult and youth educational opportunities, Jewish Women Circle events, Camp Gan Israel, senior meals and programming, CTeen chapter, and much more. Every penny contributed stays right here, working in our community, benefiting everyone. Literally thousands of lives were touched in a positive way through our activities this past year. But there is so much more to do.

Cong. Sha'arei Israel is a registered 501(c)(3) nonprofit organization. All charitable contributions are tax-deductible. You will receive a tax receipt by email or direct mail unless otherwise noted below.

We welcome you to join our membership family and enjoy being part of our wonderful community!
Personal Information
Family Name*

Address*

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

Your Details
Your First Name*
Hebrew Name
Please Choose One*

CohenLeviYisroelConvert
Birth Date*

Month Day Year
Time of Birth*

DayEvening/Night
Father's Hebrew Name*
Mother's Hebrew Name*
Work Number

Area Code Phone Number
Cell Phone Number*

Area Code Phone Number
E-mail*
Employer
Marital Status
Please select your current martial status:*

Single (never been married)MarriedDivorcedWidowed
Anniversary

Month Day Year
Please list date of divorce

Month Day Year
If you have a "get", please specify who administered it:
Spouse's Details
First Name
Hebrew Name
Please Choose One

CohenLeviYisroelConvert
Birth Date

Month Day Year
Time of Birth

DayEvening/Night
Father's Hebrew Name
Mother's Hebrew Name
Work Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
E-mail
Employer
Please list date of passing

Month Day Year
Please list approximate time of passing*

DayEvening/Night
Children
Do you have any children?

YesNo
How many children?
Child 1 Name
First Name Last Name
Child 1 Hebrew Name
Child 1 Birth Date

Month Day Year
Child 1 Gender

MaleFemale
Child 1 School
Child 2 Name
First Name Last Name
Child 2 Hebrew Name
Child 2 Birth Date

Month Day Year
Child 2 Gender

MaleFemale
Child 2 School
Child 3 Name
First Name Last Name
Child 3 Hebrew Name
Child 3 Birth Date

Month Day Year
Child 3 Gender

MaleFemale
Child 3 School
Additional Information
Have there been any conversions in the family? * (spouse, parents, grandparents, great-grandparents, etc.)

NoYes
Please Specify
Please specify Rabbinical Court the conversion was administered by:
City/State, and Year
Membership
Membership Dues & Additional Fees
My Age/Family Status is:*

Individual 18-30Family 18-30Individual 30+Family 30+Individual 70+Family 70+
Please select your preferred tier level
Individual 18-30

Platinum: $800Gold: $360Silver: $230
Family 18-30

Platinum: $2,000Gold: $1,200Silver: $550
Individual 30+

Platinum: $1,500Gold: $800Silver: $360
Family 30+

Platinum: $2,700Gold: $2,000Silver: $1,600
Individual 70+

Platinum: $1,700Gold: $1,000Silver: $600
Family 70+

Platinum: $2,000Gold: $1,300Silver: $1,000
Building Fund
Platinum Annual*

Platinum: $0.00
Gold Annual* Max. 10 years

Gold: $300
Silver Annual* Max. 10 years

Silver: $300
Security Fees
Platinum Annual*

Platinum: $0.00
Gold Annual*

Gold: $100
Silver Annual*

Silver: $100
Committees
Will you consider volunteering for one or more of our committees?
Please Select We will follow up with you!

RitualKiddushFundraisingEducationFacilities MaintenanceWomen's CircleHospitality SuiteYahrtzeitHolidaysMikvahMentsch ClubHebrew SchoolCommunity CaresFinanceMembershipHigh HolidaysJewish Art CalendarCamp Gan IsraelWelcoming Committee
Clubs Club participation is entirely voluntary.

Mens's ClubSisterhood
Additional Information
Please provide any information that the Rabbi may need to know. All information is kept confidential.
Payment Information
Total

$0.00
I would like to pay:*

Check - In FullCheck - Monthly InstallmentsCredit Card/PayPal - In FullCredit Card - Monthly InstallmentsCash - in FullCash - Monthly Installments
How many months?

Billing Address

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

Name on Card
First Name Last Name
Credit Card Number
Expiration Month
Expiration Year
Security Code

Payment*

Credit Card Paypal

Postal / Zip Code

Country

Should be Empty:

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Personal Information

Your Details

Marital Status

Spouse's Details

Children

Additional Information

Membership

Membership Dues & Additional Fees

Building Fund

Security Fees

Committees

Payment Information