Associate Membership Application

Primary Contact Name(Required)

Street Address(Required)

Home Telephone(Required)

E‑mail(Required)

Relationship to Adas Yeshurun Synagogue (prior affiliation, close relatives, etc.)

Are you currently a member of a local synagogue?(Required)

Yes

Name of Local Synagogue

Reason You Are Not a Member of a Local Synagogue

First Adult

First Adult – Full Name(Required)

First Adult – Birth Date(Required)

First Adult – Hebrew Name

First Adult – Mother’s Hebrew Name

First Adult – Father’s Hebrew Name

First Adult – Tribal Status

Cohen

Levi

Yisrael

Second Adult

Second Adult – Full Name

Second Adult – Birth Date

Second Adult – Hebrew Name

Second Adult – Mother’s Hebrew Name

Second Adult – Father’s Hebrew Name

Second Adult – Tribal Status

Cohen

Levi

Yisrael

Do you have children under 18 to include?(Required)

Yes

Children Under 18 (Name - Hebrew Name - Birth Date - School/Grade, one per line)

I understand that Associate Membership dues are currently $200/year for an individual or family, and that these may increase in the future. Fiscal year: July 1 – June 30.

I have read and understand the Associate Member policy, including that I may not be entitled to lifecycle event privileges at membership rates until I become eligible under the terms of the policy. Associate Members are not entitled to vote on Adas Yeshurun Synagogue matters.

I understand that I must be a member in good standing of a synagogue local to my home of residence in order to be an Associate Member. I will promptly notify Adas Yeshurun Synagogue if my local membership status changes.

I understand that the Rabbi has the final say on all Adas Yeshurun Synagogue religious standards.

Digital Signature

Please sign below:

Legal Notice:

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Agreement

I have read and agree to the terms above.