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100 Nassau Ave, Atlantic Beach, NY 11509
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Membership Application
Please verify reCaptcha before submitting the form.
THE JEWISH CENTER OF ATLANTIC BEACH
MEMBERSHIP APPLICATION
ADULT 1
*
Adult 1 - Title
*
Adult 1 - First Name
*
Adult 1 - Last Name
*
Adult 1 - Date of Birth
*
Adult 1 - Email
*
Adult 1 - Hebrew Name
*
Adult 1 - Tribe
Cohen
Levi
Yisrael
None Set
*
Adult 1 - Bar Mitzvah Parsha
*
Adult 1 - Father's English Name
*
Adult 1 - Father's Hebrew Name
*
Adult 1 - Mother's English Name
*
Adult 1 - Mother's Hebrew Name
Adult 1 - Mobile Phone
Adult 1 - Work Phone
Adult 1 - Employer
Adult 1 - Occupation
*
Address
*
City
*
State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Zip Code
MEMBER INTERESTS
We encourage our membership to play an active role in Synagogue life. Please choose the areas you have an interests in.
Leadership
Adult Education
Youth Programming
Library
Special Events
Membership
Kiddush Prep/Setup
Holiday Programming
Ritual Committee/Gabbi
Young Adult Programming
Music/Instruments
Torah Reading/Leading Tefila
Chessed Opportunities
Chevra Kadisha
Please upload a recent photo of this application:
Marital Status:
Single
Married
Engaged
Divorced
Widowed
Separated
N/A
Partnered
Anniversary:
If divorced, who arranged the get?
*
Is there a second adult on the account?
Please Select One
Yes
No
ADULT 2
*
Adult 2 - Title
*
Adult 2 - First Name
*
Adult 2 - Last Name
Adult 2 - Date of Birth
*
Adult 2 - Email
*
Adult 2 - Hebrew Name
*
Adult 2 - Tribe
Cohen
Levi
Yisrael
None Set
*
Adult 2 - Father's English Name
*
Adult 2 - Father's Hebrew Name
*
Adult 2 - Mother's English Name
*
Adult 2 - Mother's Hebrew Name
Adult 2 - Mobile Phone
Adult 2 - Work Phone
Adult 2 - Employer
Adult 2 - Occupation
MEMBER INTERESTS
We encourage our membership to play an active role in Synagogue life. Please choose the areas you have an interests in.
Leadership
Adult Education
Youth Programming
Library
Special Events
Membership
Kiddush Prep/Setup
Holiday Programming
Ritual Committee/Gabbi
Young Adult Programming
Music/Instruments
Torah Reading/Leading Tefila
Chessed Opportunities
Chevra Kadisha
Please upload a recent photo of this application:
Marital Status:
If divorced, who arranged the get?
Does Adult 2 live at the same address as Adult 1?
Please Select One
Yes
No
*
Address
*
City
*
State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Zip Code
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Home Phone
CHILDREN LIVING AT HOME
How many children live at home?
Please Select One
None
1 Child
2 Children
3 Children
4 Children
CHILD 1
Child 1 - Name
Child 1 - Date of Birth
Child 1 - Time of Birth
Approx. time of birth is needed to calculate your child's correct Bar/Bat Mitzvah Date.
Child 1 - Hebrew Name (English Spelling)
Child 1 - Gender
Child 1 - School
Child 1 - Grade
CHILD 2
Child 2 - Name
Child 2 - Date of Birth
Child 2 - Time of Birth
Approx. time of birth is needed to calculate your child's correct Bar/Bat Mitzvah Date.
Child 2 - Hebrew Name (English Spelling)
Child 2 - Gender
Child 2 - School
Child 2 - Grade
CHILD 3
Child 3 - Name
Child 3 - Date of Birth
Child 3 - Time of Birth
Approx. time of birth is needed to calculate your child's correct Bar/Bat Mitzvah Date.
Child 3 - Hebrew Name (English Spelling)
Child 3 - Gender
Child 3 - School
Child 3 - Grade
CHILD 4
Child 4 - Name
Child 4 - Date of Birth
Child 4 - Time of Birth
Approx. time of birth is needed to calculate your child's correct Bar/Bat Mitzvah Date.
Child 4 - Hebrew Name (English Spelling)
Child 4 - Gender
Child 4 - School
Child 4 - Grade
CHILDREN LIVING ON THEIR OWN
How many children live on their own?
Please Select One
None
1 Child
2 Children
3 Children
4 Children
CHILD 1
Child 1 - Name
Child 1 - Date of Birth
Child 1 - Place of Residence
Child 1 - Spouse Name/# of children
Child 1 - Hebrew Name (English Spelling)
CHILD 2
Child 2 - Name
Child 2 - Date of Birth
Child 2 - Place of Residence
Child 2 - Spouse Name/# of children
Child 2 - Hebrew Name (English Spelling)
CHILD 3
Child 3 - Name
Child 3 - Date of Birth
Child 3 - Place of Residence
Child 3 - Spouse Name/# of children
Child 3 - Hebrew Name (English Spelling)
CHILD 4
Child 4 - Name
Child 4 - Date of Birth
Child 4 - Place of Residence
Child 4 - Spouse Name/# of children
Child 4 - Hebrew Name (English Spelling)
YAHRZEIT INFORMATION
How many yahrzeits would you like to observe?
Please Select One
None
1 yahrzeit
2 yahrzeits
3 yahrzeits
4 yahrzeits
Name of Departed
English/Hebrew (English Spelling)
Secular Date of Passing
Jewish Date of Passing
Relationship (Specify to whom)
Name of Departed
English/Hebrew (English Spelling)
Secular Date of Passing
Jewish Date of Passing
Relationship (Specify to whom)
Name of Departed
English/Hebrew (English Spelling)
Secular Date of Passing
Jewish Date of Passing
Relationship (Specify to whom)
Name of Departed
English/Hebrew (English Spelling)
Secular Date of Passing
Jewish Date of Passing
Relationship (Specify to whom)
COMMITMENT INFORMATION
Please select your commitment level:
Please Select One
Family Membership - $2000
Single Membership - $1000
Young Family membership - $1350
Young Single - $675
Young Family Membership - Both partners under the age of 35
Young Single - Under 35
Full Members agree to contribute a minimum of $1500 to the Building Fund over a maximum period of five years. This pledge will not be in effect until the second year of membership.
+ $50 for Men's Club & Sisterhood Dues
+ $25 for Men's Club & Sisterhood Dues
+ $180 for Security Assessment
+ $90 for Security Assessment
I/we hereby apply for membership in the Jewish Center of Atlantic Beach. If elected to membership I/we will conform to and obey the constitution, by-laws and other rules and regulations of the congregation now in force or hereafter to be adopted. As a member, I/we shall be entitled to all the rights and privileges set forth in the by-laws of the Congregation.
Previous & or/other Congregational Affiliation (Name and City)
For how long?
Outstanding Financial Obligations?
Please Select One
Yes
No
Please explain:
Total Commitment
Fri, April 26 2024 18 Nisan 5784
