TBIWaltham Membership Application

Membership Information
Please tell us about you and your family and how you would like us to contact you.

Please DO NOT use all caps when completing this form.

Adult #1 Information
Adult #1 Full Name*

First NameLast Name
Adult #1 Goes by--if different from first name
Adult #1 E-mail
Adult #1 Mobile Phone

Area CodePhone Number
Adult #1 Birth Date

MonthDayYear
Date
Adult #1 Hebrew Name
Examples: Shmuel Ben Avraham v' Rachel, Shoshana Bat Chayim, Reuven miBeit Aharon v'Rivka
Adult #1 How should we call you up for an Aliyah?

KohenLeviYisraeilDon't know
Photograph Release Form I, hereby grant permission to Temple Beth Israel to use any photos that have been taken of me for the purpose of SELF USE and or SELF PROMOTION publications which can include but is not limited to, advertising, fliers, newsletters and websites without any compensation or recognition given to me. Furthermore, I grant creative permission to alter the photograph(s). I do not grant permission to resale or use the photographs in a manner that would exploit or cause malicious representation toward me. At any time I can change my decision by submitting a request in writing to Temple Beth Israel, 25 Harvard Street, Waltham, MA 02453.*

I give my permission to use photographs of meI do not give my permission to use photographs of me

Adult #2 Information
Adult #2 Name

First NameLast Name
Adult #2 Goes by--if different from first name
Adult #2 E-mail
Adult #2 Mobile Phone

Area CodePhone Number
Adult #2 Birthdate

MonthDayYear
Date
Adult #2 Hebrew Name
Examples: Shmuel Ben Avraham v' Rachel, Shoshana Bat Chayim, Reuven miBeit Aharon v'Rivka
Adult #2: How should we call you up for an ailyah?

KohenLeviYisraelDon't know
Wedding Anniversary Date

MonthDayYear
Date
Photograph Release Form I, hereby grant permission to Temple Beth Israel to use any photos that have been taken of me for the purpose of SELF USE and or SELF PROMOTION publications which can include but is not limited to, advertising, fliers, newsletters and websites without any compensation or recognition given to me. Furthermore, I grant creative permission to alter the photograph(s). I do not grant permission to resale or use the photographs in a manner that would exploit or cause malicious representation toward me. At any time I can change my decision by submitting a request in writing to Temple Beth Israel, 25 Harvard Street, Waltham, MA 02453.

I give my permission to use photographs of meI do not give my permission to use photographs of me

Membership and Contributions
The recommended sustaining membership contribution is $1,000 per individual, $2,000 per family. Please give at this level if you are able, and more if you can. If this amount is beyond your means, please specify an amount to pledge or call the office to arrange payment plan. All are welcome.

If you will be paying by credit card, please add $30/individual or $60/family contribution to defray the credit card fees.

To submit this form...
Thank you for completing this membership form. Now you can either pay with a credit card below, or you can mail a check to Temple Beth Israel, 25 Harvard Street, Waltham, MA 02453.

Payment Options
Payment Options:
- To pay by check: click SUBMIT and then send your payment to Temple Beth Israel, 25 Harvard Street, Waltham, MA 02453
- To pay by credit card (please add a 3% convenience fee) SUBMIT this form and then navigate to the Temple Website
1. pay in full at: http://www.tbiwaltham.org/engage/become-a-member/
2. pay an alternate amount at our Donate page http://www.tbiwaltham.org/give/donate-online/
Should be Empty:

	YES	NO
Can we contact you by email regarding Temple news and events?
Can we list your names and contact information in the Membership Directory?
Can we add your email to the Chesed email list so you can be informed of opportunities to reach out to the Temple community in times of joy, concern, and sorrow?
Do you want us to subscribe you to TBITalk, Temple Beth Israel's online email discussion for members only? We will use the email address provided above.
Do you want us to send you a printed copy of the monthly Temple newsletter by US Mail?

Membership Information