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Membership Application
Please verify reCaptcha before submitting the form.
WELCOME TO MIZPAH!
We are delighted you have chosen to become part of our community. We hope that you will find membership an enriching experience and encourage you to explore the diverse opportunities for Jewish expression that Mizpah offers. All information in this application will be treated confidentially. Please call our office at (423) 267-9771 if you have any questions at all or need assistance in filling out this application.
ADULT ONE
ADULT TWO (if applicable)
Title (Adult 1)
Title (Adult 2)
*
First Name (Adult 1)
Last Name (Adult 1)
First Name (Adult 2)
Last Name (Adult 2)
Adult 1 Preferred First Name (if different from above) and/or Preferred Pronouns (if applicable)
Adult 2 Preferred First Name (if different from above) and/or Preferred Pronouns (if applicable)
Hebrew Name (Adult 1)
Hebrew Name (Adult 2)
Contact Email (Adult 1)
Contact Email (Adult 2)
Contact Phone (Adult 1)
Contact Phone (Adult 2)
Birthdate (Adult 1)
Gender (Adult 1)
N/A or Unknown
Male
Female
Birthdate (Adult 2)
Gender (Adult 2)
N/A or Unknown
Male
Female
Occupation (Adult 1)
Occupation (Adult 2)
Name of Employer (Adult 1)
Employer (Adult 2)
Religious Background (Adult 1)
Reform
Orthodox
Conservative
Reconstructionist
Jewish unaffiliated
Religious Background (Adult 2)
Reform
Orthodox
Conservative
Reconstructionist
Jewish unaffiliated
Special Accommodations Needed (Adult 1)
Visual Impairment (large print prayer book)
Auditory Impairment (assisted hearing devices)
Physically challenged
Special Accommodations Needed (Adult 2)
Visual Impairment (large print prayer book)
Auditory Impairment (assisted hearing devices)
Physically challenged
Mailing Address
Address 2
City
State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Marital Status
Single
Married
Engaged
Divorced
Widowed
Separated
N/A
Partnered
Anniversary
EMERGENCY CONTACTS
Dr. Name
Dr. Contact Phone
Emergency Contact Name
Emergency Contact Phone
Relationship
PARTICIPATION OPPORTUNITIES AND INTERESTS
At Mizpah, we believe that joining a congregation is a spiritual and emotional commitment. We encourage all congregants to become involved in all aspects of life in our congregational community. In furthering this ideal, we request that upon submitting this applicationĀ you commit to participate in congregational life. Please indicate which of these areas interest you by checking the appropriate box(es). Your participation will help strengthen the community and will make your temple experience more meaningful.
Opportunities for Participation (Adult 1)
Adult Learning
Social Action Projects
Communications & Publicity
Music - Choir
Cooking
Religious School Activities
Bulletin Writing - Editing
Youth Activities
Library
Garden
Personal Interests (Adult 1)
Cooking / Baking
Travel
Outdoors - Hiking
Gardening
Sewing - Crafts
Mahjong
The Arts - Music, Shows, Galleries
History
Areas of Interest (Adult 2)
Adult Learning
Social Action Projects
Communications & Publicity
Music - Choir
Cooking
Religious School Activities
Bulletin Writing - Editing
Youth Activities
Library
Garden
Personal Interests (Adult 2)
Cooking / Baking
Travel
Outdoors - Hiking
Gardening
Sewing - Crafts
Mahjong
The Arts - Music, Shows, Galleries
History
Other Areas of Interest (Adult 1)
Other Areas of Interest (Adult 2)
CHILD ONE
CHILD TWO
CHILD THREE
CHILD FOUR
First Name (C1)
First Name (C2)
First Name (C3)
First Name (C4)
Last Name (C1)
Last Name (C2)
Last Name (C3)
Last Name (C4)
Gender (C1)
N/A or Unknown
Male
Female
Gender (C2)
N/A or Unknown
Male
Female
Gender (C3)
N/A or Unknown
Male
Female
Gender (C4)
N/A or Unknown
Male
Female
Birthdate (C1)
Birthdate (C2)
Birthdate (C3)
Birthdate (C4)
Hebrew Name (C1)
Hebrew Name (C2)
Hebrew Name (C3)
Hebrew Name (C4)
B'nei Mitzvah Date (C1)
B'nei Mitzvah Date (C2)
B'nei Mitzvah Date (C3)
B'nei Mitzvah Date (C4)
Interested in Mizpah Religious School? (C1)
Yes
No
Interested in Mizpah Religious School? (C2)
Yes
No
Interested in Mizpah Religious School? (C3)
Yes
No
Interested in Mizpah Religious School? (C4)
Yes
No
THANK YOU!
Thank you for taking the time to complete the Mizpah Membership Application. We look forward to welcoming you to Mizpah. Please allow a few days for your application to be reviewed and processed.
Fri, April 26 2024 18 Nisan 5784