MEMBERSHIP APPLICATION

Building A Caring Community

Date: ___________________

Type of Membership:   • Single  • Couple/Single Parent Family  • Family

    (Mr.)(Mrs.)(Ms.)(        ) ______________________________  Occupation _______________ 

&  (Mr.)(Mrs.)(Ms.)(        ) ______________________________  Occupation _______________

Child’s Name: ____________________________   Birthdate: ________Sex: M  F  Grade:_____

Child’s Name: ____________________________   Birthdate: ________Sex: M  F  Grade:_____

Child’s Name: ____________________________   Birthdate: ________Sex: M  F  Grade:_____

Other Family members living with you ______________________________________________

Birthdate________________________Relationship____________________________

Address ___________________________________ City _________________ Zip ___________

Phone: Day _______________________________  Evening _____________________________

Email address: ____________________________

Emergency contact: Name: _________________________________ Relationship: ___________

Telephone: ___________________ Address: _________________________________________

Yartzeit:Name _______________________ Relationship ___________ English date: ________

Name _______________________ Relationship ___________ English date: ________

Name _______________________ Relationship ___________ English date: ________

The Community will be publishing a directory of Members. Please check here for:

• telephone & address OK  • telephone listing • name only  • no listing at all

Comment below about what is important to you:   __________________________________________

___________________________________________________________________________________

Mail

P.O. Box 172

Ojai, California 93024

Click for Membership Dues schedule

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