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Membership Application

We are delighted that you have chosen to be part of our congregation. For over 170 years, members of Anshe Chesed Fairmount Temple have come together to pray, study, celebrate and support one another. We hope you find being part of our congregation an enriching experience and encourage you to explore the diverse opportunities for Jewish expression and involvement that Anshe Chesed Fairmount Temple offers. We invite you to call upon our clergy, staff and lay leaders to assist you in strengthening your connection to our community.

Please take a few moments to complete all sections of this form that apply to you. We’d like to get to know you better. Information about our members enables us to provide programming that meets the need of the entire temple community and helps us to identify opportunities to put your talents and passions into action. No personal information is shared with outside organizations.

* Name, Adult Applicant A

Title (choose one), Adult Applicant A

Mr.
Mrs.
Ms.
Dr.
Mx.

Preferred Name, Adult Applicant A

Hebrew Name, Adult Applicant A

Date of Birth, Adult Applicant A

Prefered Pronouns, Applicant A

	She / Her / Hers
	He / Him / His
	They / Them / Theirs
	Other

Home Address

City & Zip

Home Phone

Cell Phone, Adult Applicant A

Occupation, Adult Applicant A

Employer, Adult Applicant A

Work Phone, Adult Applicant A

Email, Adult Applicant A

Marriage Status

	Single
	Married
	Divorced

If married, please provide Anniversary Date:

Name, Adult Applicant B

Title (Choose One), Adult Applicant B

Mr.
Mrs.
Ms.
Dr.
Mx.

Preferred Name, Adult Applicant B

Hebrew Name, Adult Applicant B

Date of Birth, Adult Applicant B

Prefered Pronouns, Applicant B

	She / Her / Hers
	He / Him / His
	They / Them / Theirs
	Other

Home address, If different from Adult Applicant A

City & Zip, If different from Adult Applicant A

Home Phone, If different from Adult Applicant A

Cell Phone, Adult Applicant B

Occupation, Adult Applicant B

Employer, Adult Applicant B

Work Phone, Adult Applicant B

Email, Adult Applicant B

How would you like your name(s) to appear on Temple mailings? (We will do our best to accommodate your request within system capabilities)

Applicant A

How would you like your name to appear?

Applicant B

Best way to contact you:

Applicant A

Best way to contact you:

Applicant B

CHILD(REN) Information

Check here if you will be scheduling a Bar/Bat Mitzvah during the next four (4) years.

SINGLE CHILDREN

Child 1 Name (First, Middle, Last)

Birthdate - Child 1

Prefered Pronouns, Child 1

	She / Her / Hers
	He / Him / His
	They / Them / Theirs
	Other

Address, if different from above

Child 2 Name (First, Middle, Last)

Birthdate - Child 2

Prefered Prounouns, Child 2

	She / Her / Hers
	He / Him / His
	They / Them / Theirs
	Other

Address, if different from above

Child 3 Full Name (First, Middle, Last)

Birthdate - Child 3

Prefered Pronouns, Child 3

	She / Her / Hers
	He / Him ./ His
	They / Them / Theirs
	Other

Address, if different from above

Child 4 Full Name (First, Middle, Last)

Birthdate

Prefered Pronouns, Child 4

	She / Her / Hers
	He / Him / His
	They / Them / Theirs
	Other

Grade (if not at home give full current address)

Married Children

Married Name and Spouse

Birthdate

Address

Names of Grandchildren

Married Name and Spouse

Birthdate

Address

Names of Grandchildren

Married Name and Spouse

Birthdate

Address

Names of Grandchildren

Other Adults at Home

Adult 1 Full Name

Adult 1 Birthdate

Relationship with Adult 1

Adult 1 Synagogue Affiliation

Adult 2 Full Name

Adult 2 Birthdate

Relationship with Adult 2

Adult 2 Synagogue Affiliation

Member Relatives

Names of Relatives who are current members of Anshe Chesed Fairmount Temple, please provide name and relationship.

Synagogue Affiliation

Current or Previous Congregational Affiliation:

How Long Ago?

Did you participate in a Building Fund?

Clergy Contact

Would you like to arrange a personal meeting with our Clergy?

Would you like information about our cemetery?

Yahrzeit Information

If you would like the name of a loved one included on the weekly Shabbat program and read as part of the Kaddish list, please call the office by 4:00 PM on the Thursday before the Shabbat on which you would like the name read. Anshe Chesed Fairmount Temple also offers a Perpetual Yahrzeit program. For a one-time fee, we will make sure that the name of your loved one is included on the weekly Shabbat program, read as part of the weekly Kaddish list, and included in the Yahrzeit listing of the temple bulletin. You will also be sent a notice reminding you when the name will be read. In addition, a plaque with your loved ones name will be displayed.

Yes, please send me information about the Yahrzeit Program
No, thank you, not at this time

I am interested in learning more about the following:

Welcoming you in our Bulletin

Please choose one

You have my permission to announce and print my/our name(s) in the Bulletin welcoming me/us as a new and/or returning member(s)
Please do not print my/our name(s) in the Bulletin as a new member

Membership Policies

1. All new Members shall agree to an Annual Membership Commitment when applying

2. All Members when reaching age 35 years or older shall contribute to the Temple Building Fund. The Building Fund is $1500 payable over a course of five years. Please note a 10% discount will be applied if Building Fund is paid up front.

3. All new members will be automatically billed for the annual security assessment ($180).

4. Annual Membership year is July 1 to June 30.

5. A minimum payment of 25% of your total balance is necessary to process your application.

6. Beginning November we will prorate member dues.

7. You must be a member in “good standing” to be entitled to full membership privileges which include High Holiday Tickets, Religious School enrollment and access to clergy for lifecycle events.

Annual membership commitments are reviewed and adjusted at the beginning of each fiscal year.

Payment Schedule

Please select one

Annually (one payment in July)
Quarterly (one payment each in July, October, January and April)
Semi-Annually (one payment each in July and December)
Monthly* (12 months, July-June) *If you choose to pay monthly, we require you to authorize the temple to make an automatic charge to your credit card (Visa, Mastercard or Discover) or an automatic withdrawl from your checking account. Please attach a voided check to have your checking account automatically deducted

Plain Text 1

Signatures

I (we) hereby apply for membership to Anshe Chesed Fairmount Temple. If I (we) become a member, I (we) agree to abide by the By-laws, rules and regulations of the Congregation, including the timely payment of dues, fees, building fund and any other charges as approved by the Board of Directors. I (we) understand that failure to do so may result in suspension or termination of my (our) membership, but will not relieve me (us) of the obligation to pay any previously incurred dues or fees. Members must pay in full for the year in which they resign. All resignations must be in writing.

Applicant A Signature and Date

Applicant B Signature and Date

Account Details

Enter your name and e-mail address for your confirmation:

*E-mail

*First Name

*Last Name

Payment Information

Account

Credit Card

Name on Card

Card Type

Card Number

Expiration Date

Card Verification Number

Address Line 1

City

State/Province

Zip

Comments

Would you like to increase your donation to cover credit card fees. No fee for electronic checking

Total: