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Membership Application
Welcome to Congregation Rodeph Sholom. We are delighted to have you join our sacred community.
Member A Information
Prefix (Select one) *
*
Ms.
Mrs.
Mr.
Dr.
Hon.
Rabbi
Cantor
Other
If you selected "other", please tell us here
Name *
*
First
Middle
Last
Prefers to be called: *
*
Gender
Marital Status *
*
Single
Married
Partnered
Widowed
Prefer not to answer
Date of Birth *
*
Month
1
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Date of Anniversary
Month
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1932
1931
1930
1929
1928
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1926
1925
1924
1923
1922
1921
1920
Religious Upbringing
Current Religious Status
Home Address *
*
Street Address
Address Line 2
City
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
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Home Phone
Primary Email*
*
Cell Phone*
*
Billing Address *
*
Home
Business
Name of Employment
Occupation or Profession
Employment Title
Business Address
Street Address
Address Line 2
City
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
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Business Phone
Business E-mail
Have you previously been a member of Congregation Rodeph Sholom? *
*
Yes
No
If Yes, when?
Member B Information
Prefix (Select one)
Ms.
Mrs.
Mr.
Dr.
Hon.
Rabbi
Cantor
Other
If you selected "other", please tell here
Name
First
Middle
Last
Gender
Prefers to be called*
*
Date of Birth*
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
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1993
1992
1991
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1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
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1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
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1951
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Personal Email*
*
Cell Phone*
*
Religious Upbringing
Current Religious Status
Name of Employment
Occupation or Profession
Employment Title
Business Address
Street Address
Address Line 2
City
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
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Business Phone
Business E-mail
Have you previously been a member of Congregation Rodeph Sholom?
Yes
No
If Yes, when?
Relatives or friends who are now members of Rodeph Sholom:
Does anyone in your household have any special needs of which we should be aware? *
*
Yes
No
If Yes, please describe:
Do you have any children? *
*
No
Yes
Child Information
Child's Name
First
Middle
Last
Hebrew Name
Prefers to be called*
*
Gender
Date of Birth*
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
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11
12
13
14
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25
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29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
School Attending/Attended
Email
Add child
Child Information (B)
Child's Name
First
Middle
Last
Hebrew Name
Prefers to be called*
*
Gender
Date of Birth*
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
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31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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2004
2003
2002
2001
2000
1999
1998
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1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
School Attending/Attended
Email
Add a third child
Child Information (C)
Child's Name
First
Middle
Last
Hebrew Name
Prefers to be called*
*
Gender
Date of Birth*
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
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8
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22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
School Attending/Attended
Email
Add a fourth child
Child Information (D)
Child's Name
First
Middle
Last
Hebrew Name
Prefers to be called*
*
Gender
Date of Birth*
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
School Attending/Attended
Email
Add fifth child
Child Information (E)
Child's Name
First
Middle
Last
Hebrew Name
Prefers to be called*
*
Gender
Date of Birth*
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
School Attending/Attended
Email
Yahrzeit Observance
If you have loved ones whose names you would like to be [placed on our Kaddish list, regardless of their religious identity, please list the names blow. While it is customary to observe Yahrzeit on the Hebrew date of death, some members prefer to use the English date. Please let us know if you would like assistance in determining the Hebrew date. A Yahrzeit reminder letter will be sent approximately one month prior to the date.
Would you like to add a name to our Yahrzeit list? *
*
No
Yes
Yahrzeit Information
Deceased's Name
First
Last
Remembered By
Member A
Member B
Relationship
Observe*
*
Hebrew Date
English Date
Hebrew Date*
*
Hebrew Month*
*
Hebrew Year*
*
English Date
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Add a second name to our Yahrzeit list
Yahrzeit Information (B)
Deceased's Name
First
Last
Remembered By
Member A
Member B
Relationship
Observe
*
Hebrew Date
English Date
Hebrew Date*
*
Hebrew Month*
*
Hebrew Year*
*
English Date
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Add a third name to our Yahrzeit list
Yahrzeit Information (C)
Deceased's Name
First
Last
Remembered By
Member A
Member B
Relationship
Observe
Hebrew Date
English Date
Hebrew Date*
*
Hebrew Month*
*
Hebrew Year*
*
English Date
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Add a fourth name to our Yahrzeit list
Yahrzeit Information (D)
Deceased's Name
First
Last
Remembered By
Member A
Member B
Relationship
Observe
Hebrew Date
English Date
Hebrew Date*
*
Hebrew Month*
Hebrew Year*
*
English Date
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
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Yahrzeit Information (E)
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Membership Categories
Please select the appropriate membership category *
*
One adult household - includes children under age 26
Two adult household - includes children under age 26
Junior one adult household - adult under 30 years old
Junior two adult household - both adults under 30 years old
HIGH HOLY DAY SEATING LOCATION High Holy Day tickets are included in all membership categories listed above. Services are held in three locations in the Synagogue: Main Sanctuary, Schafler Forum and Schnurmacher Chapel. Children under the age of 25 and living at home or in college may receive High Holy Day tickets in unreserved seating locations upon request. Children under the age of 18 DO NOT NEED TICKETS. Arrangements can also be made for members’ children to sit in the Main Sanctuary at an additional cost. Please contact the Membership Services Department at (646) 454-3045.
I (we) prefer to sit in the following area (all locations subject to availability) *
*
Schnurmacher Chapel/Schafler Forum (UNRESERVED)
Main Sanctuary Balcony (RESERVED)
Main Sanctuary Ground Floor (RESERVED)
* The Director of Membership Services will be in touch with you shortly to discuss Main Sanctuary seating options.
Do you have a preference of the Schnurmacher Chapel or Schafler Forum?
No preference
Schafler Forum
Schnurmacher Chapel
On occasion, events at Congregation Rodeph Sholom are recorded with audio, video and/or photographic equipment. Those attending such events are respectfully asked to grant permission to Congregation Rodeph Sholom to use any such recordings for promotional and/or everyday use. *
*
I understand, and consent, to the above
CRS is committed to being accessible to all families regardless of financial circumstances. Please check here if you would like to talk about financial aid.
I would like to talk about financial aid
I (we) hereby apply for membership in Congregation Rodeph Sholom and if I (we) become a member(s) I (we) agree to abide by the by-laws, rules and regulations of the congregation. (A copy of the by-laws is available in the Executive Director’s office.)
Member A Electronic Signature *
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Date *
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Member B Electronic Signature
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