Beyt Tikkun Membership

370 Vassar Avenue

Berkeley, California 94708

FAMILY MEMBERS (Use back page for additional family)

NAME

Date of

Birth

Hebrew Name

(if applicable)

MAILING ADDRESS

EMAIL ADDRESS

HOME PHONE(S)

WORK PHONE(S)

YAHRZEIT INFORMATION

If you observe, or wish to observe, the memorial anniversary of the death of a parent, spouse, or other close family member, please list the person’s name and date of death.

Name

Date of Death

Relationship

(optional)

REGULAR MEMBERSHIP:

 Regular Membership:  Annual membership is 1% of family income, but not less than $300 for a single or $400 for a family.

Annual Dues Amount

Check enclosed payable to Beyt Tikkun

Please bill my credit card full amount

Please bill my credit card monthly  in the

Sum of $__________________per month.*

*Note: Installments only payable by credit card.

Credit Card #

Expiration Date

Three-digit verification code (found on the on the back of the card)

Name on Card

Credit card billing address (if different from address shown above)

Signature

Date

YOUNG ADULT MEMBERSHIP

 Young Adult Membership: Membership is $75 persons who are ages 21 through 29 These are the requirements for membership in this category:

1.        Be permanent residents of the Bay Area

2.        Be ages 21 through 29.

3.      Must attend Rabbi Lerner’s weekend seminar, Loving-Kindness Judaism; OR  must attend at least 4 Saturday torah studies before the end of February 2012. If you are unable to meet one of these two requirements, you will need to repay the amount for High Holy Day tickets that your annual income level would have required according to the sliding scale.