MEMBERSHIP APPLICATION
Building A Caring Community
Mail To: Temple K'hilat Ha’Aloneem Membership, P.O. Box 172, Ojai, California 93024
Membership Information (Share as much as you like)
Member Name(s)______________________________ 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_____________________________________
Relationship____________________________
Member Address __________________________ City _________________ Zip ___________
Phone: Day ____________________ Evening _____________________________
Email address: ____________________________
Emergency contact: Name: ____________________________ Relationship: _______________
Telephone: ____________________ Address: ________________________________________
Yartzeit/Anniversary of Relatives Death:
Name _______________________ Relationship ___________ English date: ________
Name _______________________ Relationship ___________ English date: ________
Name _______________________ Relationship ___________ English date: ________
Membership Dues (Check one)
Annual: __Family $825 __Couple/One Parent Family $675 __Single $425
__Family $825 __Couple/One Parent Family $675 __Single $425 After Jan 1: __Family $400 __Couple/One Parent Family $350 __Single $200
__Family $400 __Couple/One Parent Family $350 __Single $2002nd Temple: __Family $400 __Couple/One Parent Family $350 __Single $200
Dues Relief: __Request Confidential Consideration of Dues Relief
__Request Confidential Consideration of Dues ReliefPlease enclose your check (made out to “K'hilat Ha’Aloneem”) in full payment of the amount noted above or provide your credit card information
Type of card (check one)__Visa __MC __Amex __Discover
__Visa __MC __Amex __DiscoverCard Number: __________________________ Card Expiration Date (mm/yy):_____________
Check here___ and we will charge your credit card for one-quarter of the amount due in June, September, December and February. If you join mid-year we will divide the amount due by the number of remaining aforementioned billing periods.
Our membership year is from June 1 to May 31
Signature_________________________________________
Date of Application__________________________________
Please separately provide any comments regarding what is significant or important about the experience you desire from your membership at the Jewish Community of the Oaks.
