Hevrat ShalomCongregation · Rockville, MD

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Membership Application Form

Please submit your membership application below. Then complete the annual dues pledge.

You may also print this form and mail it to Hevrat Shalom Congregation, P.O. Box 3606, Gaithersburg, MD 20878.

Don't fill this out:

Personal Information

Adult 1 — First Name *

Adult 1 — Last Name *

Adult 1 — Hebrew Name

Adult 2 — First Name

Adult 2 — Last Name

Adult 2 — Hebrew Name

Address Line 1 *

Address Line 2

City

State

Zip Code

Phone *

Email *

Children

Include all unmarried children living with you, another parent, or away at school.

Number of Children *

Child 1

Name

Hebrew Name

Age

Child 2

Name

Hebrew Name

Age

Child 3

Name

Hebrew Name

Age

Child 4

Name

Hebrew Name

Age

Child 5

Name

Hebrew Name

Age

Additional Children

Yahrzeits Observed (English Date)

Number of Yahrzeits

Yahrzeit 1

Name

Relationship

Date

Yahrzeit 2

Name

Relationship

Date

Yahrzeit 3

Name

Relationship

Date

Additional Yahrzeits

Additional Information

Previous Synagogue Affiliations

Areas of Interest — please indicate any you might like to participate in or learn more about.

Adult Learning Financial Planning / Fundraising Interfaith Activities Membership Newsletter / Publicity Outreach Rabbi's Study Group Religious Education Religious School Social Activities Social Action Temple Board Youth Programs

Signature

By affixing my/our signature(s) to this application, I/we agree to abide by the Constitution and By-Laws of the congregation, and to maintain my/our membership in good standing.

Electronic Signature *

Current Date *

Phone

Next step: once your application is submitted, please complete the annual dues pledge.

Hevrat Shalom

Congregation Hevrat Shalom
P.O. Box 3606
Gaithersburg, MD 20878

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