FAMILY MEMBER #1

Last name*:
First name*:
Date of birth (m/d/yr):
Tel (preferred phone number you'd like us to use to contact you)*:
Tel (alternate):
Tel (mobile):
E-mail*:

FAMILY MEMBER #2

Last name:
First name:
Date of birth (m/d/yr):
Tel (daytime):
Tel (evening):
Tel (mobile):
E-mail:

HOME ADDRESS*

ADDITIONAL FAMILY MEMBERS
In the boxes below, please indicate children under age 21 and any other family members living at home with you. Please include the date of birth (m/d/yr).

Name	Birthdate

 

ACTIVITY/COMMUNITY INTERESTS

Religious services Adult religious education Children's religious education Festival, holiday arrangements Music Community service

Social/cultural Fundraising Youth activities Membership Publicity Other:

REGULAR MEMBERSHIP

Annual membership is 1% of family income, but not less than $300 for a single or $400 for a family. In addition, our synagogue needs help to run our normal programs and to help subsidize people to come to services who can't afford to do so. Any additional amount you can contribute is greatly appreciated.

If you'd prefer to pay by check, make it to Beyt Tikkun, send it to Leila @ Tikkun, 2342 Shattuck Ave, #1200, Berkeley, Ca. 94704, with a list of which services you will be attending and the names and emails of any of your guests and the services which they will be attending. Or call her between 9 and 5 p.m. Monday-Friday at 510-644-1200 to do credit card over the phone. ​

	Total Cost
Regular Membership Dues (please don't use a dollar sign or comma in your entry. If you've calcuated your dues as two thousand five hundred dollars, please enter 2500.00)
I wish to make an additional contribution to help defray costs for elderly, disabled, and other persons to attend services, music accompaniment, and child care expenses. (Please don't use commas or dollar signs in the amount you enter. If you want to donate two thousand dollars, enter 2000.00)
*TOTAL AMOUNT