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Membership Form
Please verify reCaptcha before submitting the form.
APPLICATION FOR MEMBERSHIP
Temple Emanuel
1163 Persinger Rd. S.W.
Roanoke, VA 24015
(540) 342-3378
*
Date
We (I) do hereby apply for membership in Temple Emanuel, a congregation dedicated to the principles of Reform Judaism. Our primary goals are the enhancement of our religious experience and the continuing education of our members and their children.
FAMILY RECORD
*
First Name
Please enter your first name
*
Last Name
Please enter your last name
Marital Status
Single
Married
Engaged
Divorced
Widowed
Separated
N/A
Partnered
Please indicate the Marital Status of the Primary Member
Date of Marriage
Please enter the date of your marriage
*
Address Line 1
Please enter the Street Address
Address Line 2
Please enter Second Line for the Address (if applicable)
*
City
Please enter the City for the Primary Member
*
State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Please enter the State of Residence for the Primary Member
*
Zip Code
Please the Zip Code for the Primary Member
*
Primary Phone Number
Please enter a Primary Phone Number for the Primary Member
Mobile Phone
Please enter a Mobile Phone for the Primary Member
Family Email Address
Please enter a family email address (if your family has one)
Previous Community/Congregational Affiliation
Please enter your previous community or congregation you were affiliated with
PRIMARY MEMBER
MEMBER 2
*
First Name (Primary Member)
Please enter the First Name of the Primary Member
First Name (Member 2)
Please enter the First Name of the Secondary member
*
Middle Name
Please enter the Middle Name of the Primary Member
Middle Name
Please enter the Middle Name of Member 2
*
Last Name
Please enter the Last Name of the Primary Member
Last Name
Please enter the Last Name for Member 2
Hebrew First Name (Primary Member)
Please enter the Hebrew First Name of the Primary Member
Hebrew First Name (Member 2)
Please enter the Hebrew First Name of Member 2
Hebrew Father's Name
Please enter the Hebrew Father's Name for the Primary Member
Hebrew Father's Name
Please enter the Hebrew Father's Name for Member 2
Hebrew Mother's Name
Please enter the Hebrew Mother's Name for the Primary Member
Hebrew Mother's Name
Please enter the Hebrew Mother's Name for Member 2
Occupation
Please enter the Occupation for the Primary Member
Occupation
Please enter the Occupation for Member 2
Business Name
Please enter the Business Name for the Primary Member
Business Name
Please enter the Business Name for Member 2
Business Address
Please enter the Business Address for the Primary Member
Business Address
Please enter the Business Address for Member 2
Business City/State
Please enter the Business City and State for the Primary Member
Business City/State
Please enter the Business City and State for Member 2
Business Zip Code
Please enter the Business Zip Code for the Primary Member
Business Zip Code
Please enter the Business Zip Code for Member 2
*
Email Address
Please enter the Email Address for the Primary Member
Email Address
Please enter the Email Address for Member 2
*
Religious Background
Reform
Conservative
Orthodox
None
Non-Jewish (Religious Affiliation)
Converted to Judaism
Please indicate the Religious Background for the Primary Member
Religious Affiliation
Reform
Conservative
Orthodox
None
Non-Jewish (Religious Affiliation)
Converted to Judaism
Please enter the Religious Affiliation for Member 2
Conversion Date
Please enter a Conversion Date for the Primary Member (if applicable)
Conversion Date
Please enter a Conversion Date for Member 2 (if applicable)
Bar/Bat Mitzvah Date
Please select the date for the Bar or Bat Mitzvah for the Primary Member (if applicable)
Bar/Bat Mitzvah Date
Please enter the Bar or Bat Mitzvah Date for Member 2 (if applicable)
Confirmation Date
Please enter the Confirmation Date for the Primary Member (if applicable)
Confirmation Date
Please enter the Confirmation Date for Member 2 (if applicable)
DEPENDENTĀ CHILDREN
Name
Hebrew Name
Birthday
School
Name
Hebrew Name
Birthday
School
Name
Hebrew Name
Birthday
School
Name
Hebrew Name
Birthday
School
CHILDREN NOT LIVING AT HOME
Name
Address
City, State, & Zip
Phone Number
Name
Address
City, State, & Zip
Phone Number
Name
Address
City, State, & Zip
Phone Number
Name
Address
City, State, & Zip
Phone Number
MEMORIALS
Family Relationship
Last Name
First Name and Initial
Date of Death
Primary Mother
Last Name
Please enter the Last Name of the Primary Member's Mother
First Name & Initial
Please enter the First Name and Initial of the Primary Member's Mother
Date of Death
Please select the Date of Death for the Primary Member's Mother
Primary Father
Last Name
Please enter the Last Name of the Primary Member's Father
First Name & Initial
Please enter the First Name and Initial of the Primary Member's Father
Date of Death
Please enter the Date of Death for the Primary Member's Father
Member 2 Mother
Last Name
Please enter the Last Name of Member 2's Mother
First Name & Initial
Please enter the First Name and Initial of Member 2's Mother
Date of Death
Please enter the Date of Death for Member 2's Mother
Member 2 Father
Last Name
Please enter the Last Name of Member 2's Father
First Name & Initial
Please enter the First Name and Initial for Member 2's Father
Date of Death
Please enter the Date of Death for Member 2's Father
Location of Family Plot
Please indicate where the family plot is located (if applicable)
Temple Emanuel Cemetery
Temple Emanuel Cemetery
I am interested in information regarding Temple Emanuel Cemetery
COMMITTEES
I would like to be involved in the following Committee(s)
PRIMARY
MEMBER 2
Committee(s) Interest
Adult Education
Brotherhood
Bulletin Production
Caring Committee
Cemetery
Choir
Fund Raising
Building and Grounds
Library
Membership
Outreach
Sisterhood
Social Action Committee
Social Activities
Special Events
Worship/Pulpit
Youth Camps
Office Volunteer
Please indicate which Committee(s) the Primary Member is interested in
Committee(s) Interest
Adult Education
Brotherhood
Bulletin Production
Caring Committee
Cemetery
Choir
Fund Raising
Building and Grounds
Library
Membership
Outreach
Sisterhood
Social Action Committee
Social Activities
Special Events
Worship/Pulpit
Youth Camps
Office Volunteer
Please indicate which Committee(s) Member 2 is interested in
Hobbies, Talents, & Interests
Please list any other special talents or interests (i.e., sing, play instrument, drama, writing, photography, etc.)
Hobbies, Talents, & Interests
Please list any other special talents or interests (i.e., sing, play instrument, drama, writing, photography, etc.)
I hereby apply for membership in Temple Emanuel, a congregation dedicated to promoting the fundamental and enduring principles of Judaism; to ensuring the continuity of the Jewish people; to enabling its members to develop a relationship with God through communal worship, study of Torah, and assembly; and to apply the principles of Reform Judaism to the values and conduct of the individual, the family and the society in which we live. We/I agree to conform to Temple Emanuel's by-laws and to honor all monetary obligations to the congregation.
Applicant(s) signature:
PRIMARY MEMBER
Signature Line
Please type your name. Please note that you are consenting to sign and agree to Temple Emanuel's by-laws and financial obligations electronically. Your typed name will be be considered as valid and binding as your signature. For any questions regarding the application process, please contact the Temple Office at (540) 342-3378 or
office@teroanoke.org
.
Date
Please enter a date for when this form was signed
MEMBER 2
Signature Line
Please type your name. Please note that you are consenting to sign and agree to Temple Emanuel's by-laws and financial obligations electronically. Your typed name will be be considered as valid and binding as your signature. For any questions regarding the application process, please contact the Temple Office at (540) 342-3378 or
office@teroanoke.org
.
Date
Please enter a date for when this form was signed
Thu, September 21 2023 6 Tishrei 5784