Rosh Pina Membership Survey

Household Information

First Name

Last Name

Email

Phone Number

Hebrew Name

Children aged 12 and up are counted as adults.

How many adults in your household are you responding for? (Total Including Yourself)

Name of Adult 2 in Household

Email Address of Adult 2

Hebrew Name of Adult 2

Name of Adult 3 in Household

Email Address of Adult 3

Hebrew Name of Adult 3

How many children in your household are you responding for?

Name of Child 1

Name of Child 2

Name of Child 3

Name of Child 4

Name of Child 5

Special Dates

Bar/Bat Mitzvah Parsha

Bar/Bat Mitzvah Parsha of Adult 2

Bar/Bat Mitzvah Parsha of Adult 3

When are the yahrzeits of any of your family members? For each, include your family member's name, relationship, and Hebrew yahrzeit.

Volunteer Opportunities

Rosh Pina is able to thrive due to our volunteer spirit. How will you be able to volunteer for us this year?

In what way would you like to be involved in services? Select all that apply. If you would like to learn how to do any of these things, please specify in Other.

Yom Kippur

Would you like to order tickets for Rosh Pina's Yom Kippur services?

Each full membership donation of at least $200 comes with one free Yom Kippur ticket. Children aged 12 and up require a Yom Kippur ticket. You can purchase this ticket separately from membership for $80, or with membership. Children below age 12 do not need a ticket and are welcome to join services for free. We are committed to ensuring that everyone can be a full member of our community and attend Yom Kippur, regardless of financial circumstance. Please contact the Vaad confidentially at info@roshpinadc.org if you would like to discuss other pricing options for Yom Kippur.

Please click here to see the Yom Kippur schedule.

Number of Yom Kippur tickets needed (ages 12 and up) -- men's side of the mechitza:

Number of Yom Kippur tickets needed (ages 12 and up) -- women's side of the mechitza:

My Products

Rosh Pina Membership Donation with Yom Kippur Ticket$200.00

Quantity

Rosh Pina Membership Donation without Yom Kippur Ticket $200.00

Quantity

Yom Kippur Guest Ticket$80.00

Quantity

I would like to donate an amount other than $200 for Rosh Pina membership (payment instructions will be given after you press submit)Free

Total $0.00