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Membership Application

Please complete all sections of the Membership Application.

First Adult

* Name

First, Middle, Last

Preferred Pronouns

Hebrew Name

E-Mail

Birth Date

Work Phone

Home Phone

Other Phone

Fax, Cell etc.

Profession

Second Adult

Name

First, Middle, Last

Hebrew Name

Preferred Pronouns

E-Mail

Birth Date

Work Phone

Home Phone

Cell Phone

Profession

Household Information

Home Address

Street, City, State, Zip

Children In Household

Child 1

Name

Birthdate

Hebrew Name

Child 2

Name

Birthdate

Hebrew Name

Child 3

Name

Birthdate

Hebrew Name

Child 4

Name

Birthdate

Hebrew Name

Yahrzeits (Remembrances of Loved Ones)

Please list the name and date of death for loved ones whose yahrzeits you wish to be remembered at the Shabbat service preceding the anniversary date. Yahrzeit observances follow the Hebrew calendar, but you may request the secular date if preferred. Our database will calculate the Hebrew date from the secular date provided the year of death is included.

Check Here to observe on a secular or Hebrew date

Secular

Hebrew

Yahrzeit 1

Name

Hebrew name also, if known

Relationship

Date

Secular Date and Time of Day (AM or PM) or Hebrew Date (if known). YEAR OF PASSING NEEDED

Yahrzeit 2

Name

Hebrew name also, if desired

Relationship

Date

Secular Date and Time of Day (AM or PM) or Hebrew Date (if known). YEAR OF PASSING NEEDED

Yahrzeit 3

Name

Hebrew name if known

Relationship

Date

Secular Date and Time of Day (AM or PM) or Hebrew Date (if known). YEAR OF PASSING NEEDED

Yahrzeit 4

Name

Hebrew name also, if known

Relationship

Date

Secular Date and Time of Day (AM or PM) or Hebrew Date (if known). YEAR OF PASSING NEEDED

Yahrzeit 5

Name

Hebrew name also, if known

Relationship

Date

Secular Date and Time of Day (AM or PM) or Hebrew Date (if known). YEAR OF PASSING NEEDED

Yahrzeit 6

Name

Hebrew name also, if known

Relationship

Date

Secular Date and Time of Day (AM or PM) or Hebrew Date (if known). YEAR OF PASSING NEEDED

Personal Interests

Wedding Anniversary

(if applicable) Month, Day, Year

Do you have any skills or special talents you would be willing to share with us?

Sing, play an instrument, Chant Torah, Teach, Bake, Cook

How would you like to be involved in our synagogue community?

For Ways to engage: would you like to participate in a service, could you lead a service, can you garden.

Please feel free to provide any additional information below:

Consent to use photographs taken at synagogue-related events on the synagogue's website and other published congregational materials will be assumed unless the synagogue office is notified. Notification to opt out of this policy must be made in writing.

I am interested in the following activities (check all that apply)

Adult Education

Brotherhood

Building Beautification

Choir

Community Service

Hebrew (reading/speaking)

Lay Leader

Library

Music

Planning

Oneg/Kiddush

Sisterhood

Social Events

Teaching (adult/children)

Ushering

Yoga/Tai Chi

I am interested in the following committees (check all that apply)

Adult Education

Archives (Historian)

Brotherhood

Caring

Communication

House/Facilities

Finance

Fine Arts

Library

Membership

Sisterhood

Social Action

Social Events

Ways and Means

Worship/Ritual

Youth Education

Pledge Information

* We are applying for

New Member Fee Only (for 2 years thru June 30,2026) $3,600.00

1 Adult $2,255.00

2 Adults $3,355.00

Chai Society Family $4,070.00

Fair Share Dues (TBC's per household cost) $5,500.00

Benefactor Dues $6,050.00

Mensch Dues $11,000.00

* Security Fee (Required)

$400.00

Optional Donations

PTO $72.00

URJ Appeal $18.00

Sisterhood Dues $60.00

Arza $36.00

* Dues Relief Form

If you are requesting dues relief (even if you were granted dues relief for the current fiscal year), please download the form at https://templebnaichaim.org/tbc-forms/. Complete the form and include it with your membership renewal. Requests for dues relief will be reviewed promptly in the order received. All requests are reviewed in the strictest confidence to ensure complete privacy, your information will only be available to the Dues Relief Committee which consists of the President, Past President and the Treasurer. Please send in the form no later than July 31st in order not to delay High Holiday Tickets!

High Holiday Memorial Book for Yizkor Service List Names

Amount of Donation

$1,800.00

$1,500.00

$1,000.00

$500.00

$360.00

$180.00

$90.00

$54.00

$18.00

The Synagogue Building Fund is dedicated to our facility. Your minimum mandatory contribution to The Synagogue Building Fund is:

* Payment Options

Yearly payment of $450 for 6 years $450.00

* Billing Frequency

8 Months

4 Payment

Paid in Full

AUTHORIZATION: My/Our account will remain subject to its individual terms and conditions, which are not modified by this authorization. I/We understand that this authorization will remain in its full force and effect until Temple B'nai Chaim has received written notification from me/us of its termination in such time and in such manner as to afford TEMPLE B'NAI CHAIM and the DEPOSITOR a reasonable opportunity to act on it. If my/our account is closed or does not contain the necessary funds to cover the automated withdrawal, then it is my/our responsibility to notify Temple B'nai Chaim of such changes in writing before the next scheduled automated withdrawal and make alternate arrangements, such as providing a new account number. Failure to do so will result in instantaneous termination of automated withdrawal, and I/we shall immediately pay the balance of remaining outstanding charges in order to remain members in good standing.

Signature

NOTE: Recurring automated withdrawals are scheduled for the 15th of the month. If the scheduled date of an automated withdrawal falls on a holiday or a weekend, Temple B’nai Chaim will initiate the automated withdrawal on the next business day. Members who enroll after the first recurring automated withdrawal will immediately be debited for any missed payments; the remainder will be debited as per above schedule.

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Account Details

E-mail

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First Name

Last Name

Payment Information

Account

Online Fee:

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Checking Account

Name on the Account

Bank Name

Routing Number

Is usually located between the symbols on your check.

Account Number

Typically comes before the symbols. Its exact location and number of digits varies from bank to bank.

Confirm Account Number

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