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PO Box 1378
Rabbi Leon A. Morris                                 Sag Harbor, NY  11963                                   Neal Fagin, President

MEMBERSHIP APPLICATION

I hereby apply for membership in TEMPLE ADAS ISRAEL, a Reform Jewish Congregation affiliated with the Union for Reform Judaism, and subscribe to the statement of purpose of the Temple as defined in its by-laws: “To maintain a house of worship for persons of the Jewish Faith; to provide spiritual guidance, moral and ethical teaching according to the faith of our Fathers and Mothers; to perpetuate the traditions of Jewish learning and culture; and to provide a center for the social life of the Jewish community.”

Type of membership (please select one) 

 (   )  Individual: Annual dues $500; Building Fund Commitment $750*

 (   )Family (including dependent children): Annual dues $1,000; Building Fund Commitment $1,500*
 

Are you a member of another Reform congregation?    (   ) YES ---  (   ) NO
   

Member #1_________________________________

Member #2_______________________________
 Phone: Home ______________________________  Phone: Home ____________________________
            Business ____________________________             Business __________________________
            Cell ________________________________             Cell ______________________________
 Email: _________________________________________  Email: _______________________________________
 Dependent Children:  
 Name: ____________________________________  Date of Birth: _____________________________
 Name: ____________________________________  Date of Birth: _____________________________
 Name: ____________________________________  Date of Birth: _____________________________
 Name: ____________________________________  Date of Birth: _____________________________
 Primary Address: __________________________  Effective dates:
 __________________________________  From ___________  to _____________
 __________________________________  
 __________________________________  
 __________________________________  Phone: __________________________________
 Secondary Address: _______________________  Effective dates:
 __________________________________  From ___________  to _____________
 __________________________________  
 __________________________________  
 __________________________________  Phone: __________________________________
 Yahrzeits you would like remembered:  Relationship __________  Date of Death _______
 __________________________________                 ________                    ______
 __________________________________                 ________                    ______
 __________________________________                 ________                    ______
 __________________________________                 ________                    ______
   
  Signature: ___________________________  Date: _______________________

Temple Adas Israel: adasisrael11963@optonline.net or 631-725-0904

Temple Administrator, Margaret Bromberg: adasisrael11963@optonline.net or 631-725-0904 

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