LY - Membership Application Form

Membership Application

To apply for membership please complete all questions.
I am applying for a...*
Name*

First NameLast Name
Birthday

MonthDayYear
Date
Spouse's name

First NameLast Name
Spouse's Birthday

MonthDayYear
Date
Email*
example@example.com
Spouse's Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Spouse's Phone Number
Previous Synagogue, if applicable
If none, leave blank
Marital Status*
Wedding Anniversary (If Married)

MonthDayYear
Date
I am...*
My spouse is...

We'd love to be able to celebrate birthdays together as a community.

Please tell us about your family, if applicable.

This section is optional.
Child # 1
First Name
Birthday

MonthDayYear
Date
Child # 2
First Name
Birthday

MonthDayYear
Date
Child # 3
First Name
Birthday

MonthDayYear
Date
Child # 4
First Name
Birthday

MonthDayYear
Date
Child # 5
First Name
Birthday

MonthDayYear
Date

Yahrtzeits

The Hebrew anniversary of a loved one's passing is marked by remembering the departed and doing things to elevate the soul. If you have any loved ones that you would like to keep on record, please enter them here.

This section is optional.
Name of departed # 1

First NameLast Name
Hebrew name of departed
Father's Hebrew name
Relationship to you
Below, enter the Hebrew date of passing. If you only know the regular date, click here to access a Hebrew date converter.
Day
Month
Name of departed # 2

First NameLast Name
Hebrew name of departed
Father's Hebrew name
Relationship
Below, enter the Hebrew date of passing. If you only know the regular date, click here to access a Hebrew date converter.
Day
Month
Name of departed # 3

First NameLast Name
Hebrew name of departed
Father's Hebrew name
Relationship
Below, enter the Hebrew date of passing. If you only know the regular date, click here to access a Hebrew date converter.
Day
Month
Name

First NameLast Name
Name

First NameLast Name
Name of departed # 4

First NameLast Name
Hebrew name of departed
Father's Hebrew name
Relationship
Below, enter the Hebrew date of passing. If you only know the regular date, click here to access a Hebrew date converter.
Day
Month

My Products*

Monthly paymentsOn the next screen, upon submitting the membership application, you will see a link to a separate page to set up monthly payments. Your membership is not complete until those payments have been set up.

$ Free

Pay now - Standard Membership (Family)

$950.00

Pay now - Associate Membership (Family)This is an option for people who are already members at another shul. Associate members do not have voting rights or other member privileges.

$450.00

Pay now - Chai MembershipChai Membership entitles you to free High Holidays registration.

$1,800.00

Pay now - Individual membershipFor a single person household.

$550.00

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty: