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Congregation Ahavath Chesed, Jacksonville, FL
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September 09, 2010   1 Tishrei 5771
Membership Form Page 1  

Adult #1 Adult #2

Full Name

Hebrew Name

How would you like your name listed in Temple Directory?

Home Address

City, State, Zip

Area code

( )

Home Phone

Area code

( )

Area code

( )

Business Phone

Area code

( )

Occupation

Business/Employer Title

Business Address

Business City, State, Zip

Type of Business

Your Title

Your highest academic grade or degree & school

____/____/____

Month/Day/Year of Birth

____/____/____

City of Birth

( ) Yes ( ) No

Are you Retired?

( ) Yes ( ) No

Mother Father

( ) Yes ( ) No ( ) Yes ( ) No

Are your parents living?

Mother Father

( ) Yes ( ) No ( ) Yes ( ) No

( ) Yes ( ) No

Do your parents live with you?

( ) Yes ( ) No

( ) Yes ( ) No

Are your parents members of TEMPLE?

( ) Yes ( ) No

( ) Yes ( ) No

Do our parents live in the Jacksonville area?

( ) Yes ( ) No

If no, where?

( ) Yes ( ) No

Do your parents live in a Nursing Home?

( ) Yes ( ) No

Years

How long have you lived in the Jacksonville area?

Years

____________________________
____________________________
____________________________

____________________________

Names of Jewish Organizations

(and positions held)

of which you are a member

____________________________
____________________________
____________________________

____________________________

____________________________
____________________________
____________________________

____________________________

Names of Civic

Organizations

(and positions held)

of which you are a member

____________________________
____________________________
____________________________

____________________________

Membership Form Page 2  

Adult #1 Adult #2

_____________________________
_____________________________
_____________________________
_____________________________

Names of Professional

Organizations

(and positions held)

of which you are a member

____________________________
____________________________
____________________________
____________________________

Jewish

( ) By Birth ( ) By Choice ( )Non Jewish

What is your religious status?

Jewish

( ) By Birth ( ) By Choice ( )Non Jewish

Marital / Relationship Status

______/______/______

Month/Day/Year

Of present marriage

______/______/______

Name of previous congregation

City & State of

previous congregation

( ) Reform ( ) Conservative

( ) Orthodox ( ) Other ____________

Type of Jewish Background

( ) Reform ( ) Conservative

( ) Orthodox ( ) Other ____________

( ) Bar/Bat Mitzvah ( )Jewish/Hebrew Day School

( ) Confirmation ( ) Post- Conf. Religious Schooling

Please check all that apply to you:

( ) Bar/Bat Mitzvah ( )Jewish/Hebrew Day School

( ) Confirmation ( ) Post- Conf. Religious Schooling

CHILDREN

Child’s Date of Year

Full Date of Sex Hebrew Bar/Bat of

Name Nickname Birth M-F Name Mitzvah Confirmation

FULL ADDRESS OF CHILDREN (IF NOT AT HOME)

NAME ADDRESS

Please give the names of other relatives you have in TEMPLE and how they are related to you:

NAME RELATIONSHIP

YAHRZEITS OBSERVED

DATE OBSERVED

Full Name Relationship Hebrew English

Membership Form Page 3  

Are there any support services such as those listed below in which you, as an individual, could offer help: Please check. Preference for Committee Assignments.

Adult #1 Adult #2

Administration & Personnel

Adult Activities

Archives

Cemetery

House

Insurance

Interfaith

Library

Membership

Memorial & Dedications

Messenger

Music

Public Relations

Religious Education

Social Action

Ways and Means

Worship

Youth Activities

Talent Bank

[ ] Typing [ ] Clerical

Office Assistance

[ ] Typing [ ] Clerical

[ ] Teacher [ ] Substitute

Hebrew

[ ] Teacher [ ] Substitute

[ ] Teacher [ ] Substitute

TIR

[ ] Teacher [ ] Substitute

[ ] Mitzvah Marines [ ] ACYC

[ ] JAFTY

Youth Group Advisor

[ ] Mitzvah Marines [ ] ACYC

[ ] JAFTY

[ ] Mitzvah Marines [ ] ACYC

[ ] JAFTY

Youth Group Chaperone

[ ] Mitzvah Marines [ ] ACYC

[ ] JAFTY

Other Interests:

Describe:


- Jacksonville, FL - (904) 733-7078
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