Immersion Donation Form

Full Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

I agree to receive text messages from Metro Atlanta Community Mikvah (MACoM) related to my appointment, scheduling, reminders, and other service-related communications. These messages are not promotional or marketing messages. Message frequency varies. Message and data rates may apply. Reply STOP to opt out at any time.

What is your age range?

Gender

E-mail

Home Address

Street Address

Street Address 2

CityState

Zip

What is your connection to Judaism

Are you affiliated with a synagogue?

Which one?

What is the name and city of your Synagogue?

Immersion Type

What is the name of the primary rabbi officiating your conversion?

Reason for Personal Immersion

Please coordinate with your rabbi to determine your conversion date and time.

72-hour advance notice is required!

Personal Mikvah visits are allotted one hour, conversions are allotted additional time. Please select two dates/times and we will do our best to accommodate you. Not available on Shabbat or Jewish Holidays.

Please note: If you submit a scheduling request on a weekend or Jewish holiday, we will contact you on the next business day.

First Choice Date

Second Choice Date

Please note: If you submit a scheduling request on a weekend or Jewish holiday, we will contact you on the next business day.

Guide and/or Witness

When visiting MACoM, you will always be greeted by a guide who walks you through the entire process and ensures you have everything you need. However, personal immersions for reasons other than conversion do not always require a witness in the Mikvah room. Would you like to have a witness to confirm the 'kashrut' of each dunk under the water or would you rather be allowed the space to immerse on your own?

Suggested Donations

We welcome everyone regardless of their ability to give. The amounts below are suggested donations that help sustain MACoM's mission.

If none of these amounts feel comfortable, please select “Other” and enter an amount that works for you.

Suggested Donations

Donation Amount- Conversion Immersion

Other

Donation Amount- Wedding Immersion

Other

Donation Amount- Personal Immersion

Other

Donation Amount- Niddah (monthly) Immersion

Other

Calculated donation pre cc1

Is there anything else you would like to share with us?

CALCULATED DONATION-PRE CC

FINAL CALC DONATION

Donation Amount (includes 3% processing fee)

USDDescription

Debit or Credit Card
Credit Card Number	Security Code
Expiration Month	Expiration Year

Donation Amount (includes 3% processing fee)*

Donation Amount (includes 3% processing fee)