Adult One Information

Adult 1 First Name

Adult 1 Last Name

Date of Birth

Hebrew Name:

example: Josef ben Shlomo v'Miriam
(your Hebrew name (ben or bat) father and/or mother's Hebrew name)

Preferred Pronoun:

Cell Phone Number

xxx-xxx-xxxx

Email Address:

example@email.com

Adult Two Information (If applicable)

Adult 2 First Name

Adult 2 Last Name

Date of Birth

Hebrew Name:

example: Josef ben Shlomo v'Miriam
(your Hebrew name (ben or bat) father and/or mother's Hebrew name)

Preferred Pronoun:

Cell Phone Number

xxx-xxx-xxxx

Email Address:

example@email.com

Anniversary Date (If applicable):

Primary Residence Information

Address Line 1

Address Line 2

City

Zipcode

Home Phone Number (if applicable)

xxx-xxx-xxxx

Secondary Residence Information (if applicable)

Address Line 1

Address Line 2

City

Zipcode

Home Phone Number (if applicable)

xxx-xxx-xxxx

Children (Under 18 years of age)

Child 1

First Name

Last Name

Date of Birth

Preferred Pronoun:

Child 2

First Name

Last Name

Date of Birth

Preferred Pronoun:

Child 3

First Name

Last Name

Date of Birth

Preferred Pronoun:

Child 4

First Name

Last Name

Date of Birth

Preferred Pronoun:

Is your child (or children) interested in attending our Religious School?

Are you interested in receiving more information about our Religious School?

Please select which membership best suits you:

Family Membership (For families with two or more people living at home)Individual Membership (For one adult living at home)Associate Membership (For those who belong to another congregation)

Select your annual dues contribution amount to Temple B'rith Shalom

Please note these amounts include a $100 annual security fee

Nobody is denied membership due to financial hardship. Please don't hesitate to contact the office by email (office@brithshalom-az.org) or by calling 928-708-0018 to make a confidential financial arrangement.

Tzedakah Circles

Shalom- The Circle of Peace ($3600 Family, $2500 Individual)Tikvah- The Circle of Hope ($2800 Family, $2000 Individual)Nadiv- The Circle of Generosity ($2000 Family, $1500 Individual)Temple B’rith Shalom Is here to always ensure there is a strong and thriving Jewish Presence in the greater Prescott area. We are grateful to those able to pay above and beyond.

Other Annual Dues Contribution Amount:

Preferred Payment Method:

Personal Check (I will mail my dues directly to the temple)BillPay (I will arrange for my bank to send a check on my behalf)Credit Card (3% Transaction fee will be applied)

Payment Frequency:

MonthlyAnnuallyBi-AnnuallyQuarterly

I Agree to pay Temple B'rith Shalom for the 2023-2024 Membership Year: (July 1-June 30)

Annual Membership Dues

Religious School Tuition ($300 first child, $250 second child, $200 each additional child)

Additional Donation

Total:

Yahrzeit Information

Temple B’rith Shalom embraces the tradition of remembering and honoring family members who have enriched our lives, but who are no longer with us. Please provide the information requested below so we may include your loved ones on our Yahrzeit List.

Name

Relationship

Date of passing:

Do you wish to observe the Hebrew or the civil date of passing?

Hebrew DateCivil Date

What time of day did your loved one's passing occur?

Before sunsetAfter sunset

Name

Relationship

Date of passing:

Do you wish to observe the Hebrew or the civil date of passing?

Hebrew DateCivil Date

What time of day did your loved one's passing occur?

Before sunsetAfter sunset

Name

Relationship

Date of passing:

Do you wish to observe the Hebrew or the civil date of passing?

Hebrew DateCivil Date

What time of day did your loved one's passing occur?

Before sunsetAfter sunset

Name

Relationship

Date of passing:

Do you wish to observe the Hebrew or the civil date of passing?

Hebrew DateCivil Date

What time of day did your loved one's passing occur?

Before sunsetAfter sunset

Name

Relationship

Date of passing:

Do you wish to observe the Hebrew or the civil date of passing?

Hebrew DateCivil Date

What time of day did your loved one's passing occur?

Before sunsetAfter sunset

Name

Relationship

Date of passing:

Do you wish to observe the Hebrew or the civil date of passing?

Hebrew DateCivil Date

What time of day did your loved one's passing occur?

Before sunsetAfter sunset

Name

Relationship

Date of passing:

Do you wish to observe the Hebrew or the civil date of passing?

Hebrew DateCivil Date

What time of day did your loved one's passing occur?

Before sunsetAfter sunset

Name

Relationship

Date of passing:

Do you wish to observe the Hebrew or the civil date of passing?

Hebrew DateCivil Date

What time of day did your loved one's passing occur?

Before sunsetAfter sunset

If you have additional loved one's names to add, please email the office at office@brithshalom-az.org.

Do we have your permission to publish your contact information in our membership directory?

YesNoThis includes phone numbers, email, and home address unless you specify otherwise.

Please provide additional comments here:

Get Involved!

Temple B'rith Shalom offers a wide variety of activities and committees sure to appeal to everyone's interest. Please select the activities and committees that interest you.

If you are interested in an activity that isn't listed above, please let us know!

Please write your email below to receive confirmation your membership application has been received:

Welcome to Temple B'rith Shalom, your spiritual home in the high desert. We look forward to getting to know you!

Online Membership Application

Please select which membership best suits you: