Member's NameHebrew Name (English transliteration) (son of)

Spouse's NameHebrew Name (English transliteration) (daughter of)

Child's Name and AgeChild's Name and Age

Child's Name and AgeChild's Name and Age

AddressCity/Zip Code

Phone No. (xxx-xxx-xxxx)E-Mail Address

Type of Membership: (Annual Fee)
QTY
 Guardian  $1,800 (includes 4 High Holiday Seats)
 Family Membership  $900 (includes 2 High Holiday Seats)
 Single Adult  $450 (includes 1 High Holiday Seat)
 Student Member  $100 (includes 1 High Holiday Seat)
 Associate Member  $360 (does not include seat)

For full paying members of another shul
 Extra Seats (each) $100
 Extra Seats (non-members) $250
 1st Year Family Membership  $350 includes 2 High Holiday Seats
 Please indicate if you do not need seats this year

---

$  Voluntary Contribution
$  Building Fund Contribution
$  Mikveh Fund Contribution
$  Deposit Paid

---

Date

---

All financial information is strictly confidential. Please call Joel Seidel, President, at (818) 718-7606, if you have any special needs.