Congregation Am Chai
Membership Form

Items with an asterisk (*) are required               
When you click on the Send button below, your information will be emailed to the Congregation Membership Chairperson who will contact you as soon as possible.

NOTE: Please enter all dates as month/day/year (mm/dd/yyyy)

First Name of Member:*  Last Name of Member:* 

   Member Birthday   

Name of Additional Member (if needed, such as spouse with different surname)

First      Last      Birthdate   

Address (Street):*   City:*    State:*   Zip Code:*  

Home Phone:* (with area code) (###-###-####)   Work Phone: (with area code) (###-###-####)  

Email address:*       Anniversary Date (if married):   

Tribe:          How did you hear about Am Chai?  

Please list the names and birthdates of your household members below

Name                                                       Relationship        Birthdate

(Include last name if different                 (wife,husband,

than Member's)                                          son, etc.)

1                

2                

3                

4                

5                

Please list Yahrzeit below
Name                                                         Relationship        Date

1                

2                

3                

4                

5                

6                

7                

8                

9                

10               

Membership type: *

                   All interfaith couples are welcome at the Single rate



revised 08/06/2010