Mekor Shalom Membership Connections Form - Form

Dear Friends,

What draws each of us into a community?

I believe that a desire to connect plays a large role in what brings us into a community. Each one of us deserves to feel a connection to those around us, to feel a sense of belonging. Each one of us deserves to feel a connection to God and to the teachings of our tradition.

It is with this in mind that I am delighted that you are interested in Congregation Mekor Shalom. Mekor Shalom means Source of Peace. Mekor Shalom is a community where each person matters — your presence, your feelings, and your neshama (your soul). At Mekor Shalom, each of us is welcomed and celebrated for who we are.

I want to invite you to become a part of this sacred community. The weaving of the presence of each person into the communal tapestry is a blessing. Having your uniquely beautiful colors as a part of the tapestry will enrich and enhance Mekor Shalom infinitely. Each one of us has the unlimited potential to be a source of peace for ourselves and for the entire community.

Please feel free to contact me with any questions, comments, concerns, or ideas.

May God, the Source of Peace and Source of all Creation, guide us on this spiritual journey of connection.

B’shalom,

Hazzan Jodi M. Sered-Lever,

Founding Spiritual Leader

Adult #1

* Title:

* Last Name:

* First Name:

Middle Name:

* Address:

* City:

* State:

* Zip Code:

* Email address:

* Preferred phone number:

* Is this phone number is a mobile number?

Please Select OneYesNo

Please check here if you would like to be listed in the member directory.

Gender Identity:

Pronouns:

Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination)

Date-of-Birth:

* Please indicate whether you are:

Jewish by BirthJewish by Choicea Supportive Partner/Spouse

Hebrew Name (First & Middle, if applicable):

English or Hebrew letters may be entered in the name fields.

Hebrew Name of Parent (if applicable):

Please indicate, if applicable, whether you are a:

KohenLeviYisraelI don't know.If you aren't sure, that's fine!

Wedding anniversary date (if applicable):

Occupation(s) or retired (If retired, please share your professional field, e.g. retired accountant or retired physicist):

If need be, may Mekor Shalom contact you at work?

YesNoNot applicable

If yes, work number is:

Ideas and suggestions to share:

Adult #2

Title:

Last Name:

First Name:

Middle Name:

Address, if different from Adult #1:

Email address:

Preferred phone number:

Is this phone number is a mobile number?

YesNo

Please check here if you would like to be listed in the member directory.

Gender Identity:

Pronouns:

Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination)

Date-of-Birth:

Please indicate whether you are:

Jewish by BirthJewish by Choicea Supportive Partner/Spouse

Hebrew Name (First & Middle, if applicable):

English or Hebrew letters may be entered in the name fields.

Hebrew Name of Parent (if applicable):

Please indicate, if applicable, whether you are a:

KohenLeviYisraelI don't know.If you aren't sure, that's fine!

Wedding anniversary date (if applicable):

Occupation(s) or retired (If retired, please share your professional field, e.g. retired accountant or retired physicist):

If need be, may Mekor Shalom contact you at work (if applicable)?

YesNoNot applicable

If yes, work number is:

Ideas and suggestions to share:

Dependent Children & Dependent Adults

Child or Dependent Adult #1

* Last Name:

First Name:

Middle Name:

Gender Identity:

Pronouns:

Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination)

Date-of-Birth:

Hebrew Name (First & Middle, if applicable):

English or Hebrew letters may be entered in the name fields.

Parent #1's Hebrew Name (if applicable):

Parent #2's Hebrew Name (if applicable):

Email address (if applicable):

Cell phone number (if applicable)

Religious Education Plan (for school age children):

Mekor Shalom Religious SchoolHillel AcademyAlternativeNot applicable

Child or Dependent Adult #2

Last Name

First Name

Middle Name:

Gender Identity:

Pronouns:

Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination)

Date-of-Birth:

Hebrew Name (First & Middle, if applicable):

English or Hebrew letters may be entered in the name fields.

Parent #1's Hebrew Name (if applicable):

Parent #2's Hebrew Name (if applicable):

Email address (if applicable):

Cell phone number (if applicable)

Religious Education Plan (for school age children):

Mekor Shalom Religious SchoolHillel AcademyAlternativeNot applicable

Child or Dependent Adult #3

Last Name

First Name

Middle Name:

Gender Identity:

Pronouns:

Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination)

Date-of-Birth:

Hebrew Name (First & Middle, if applicable):

English or Hebrew letters may be entered in the name fields.

Parent #1's Hebrew Name (if applicable):

Parent #2's Hebrew Name (if applicable):

Email address (if applicable):

Cell phone number (if applicable)

Religious Education Plan (for school age children):

Mekor Shalom Religious SchoolHillel AcademyAlternativeNot applicable

Child or Dependent Adult #4

Last Name

First Name

Middle Name:

Gender Identity:

Pronouns:

Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination)

Date-of-Birth:

Hebrew Name (First & Middle, if applicable):

English or Hebrew letters may be entered in the name fields.

Parent #1's Hebrew Name (if applicable):

Parent #2's Hebrew Name (if applicable):

Email address (if applicable):

Cell phone number (if applicable)

Religious Education Plan (for school age children):

Mekor Shalom Religious SchoolHillel AcademyAlternativeNot applicable

Date-of-Birth:

Remembering Loved Ones Who Have Died: Yahrzeit Information

First Name

Last Name

Relationship to (e.g. parent of):

English Date of Death:

Death Occurred before Sundown:

Please indicate yes or no.

Hebrew Date of Death (if known):

First Name

Last Name

Relationship to (e.g. parent of):

English Date of Death:

Death Occurred before Sundown:

Please indicate yes or no.

Hebrew Date of Death (if known):

First Name

Last Name

Relationship to (e.g. parent of):

English Date of Death:

Death Occurred before Sundown:

Please indicate yes or no.

Hebrew Date of Death (if known):

First Name

Last Name

Relationship to (e.g. parent of):

English Date of Death:

Death Occurred before Sundown:

Please indicate yes or no.

Hebrew Date of Death (if known):

Additional Yahrzeit Names and Information (if applicable):

Name:

Relationship:

Best Contact Phone Number:

Name:

Relationship:

Best Contact Phone Number:

Name:

Relationship:

Best Contact Phone Number:

A Request for Photographs:

Please Select OneI/we agree.I/we do not agree.I/we give permission to Congregation Mekor Shalom to photograph our household members, including child(ren) if applicable, to use image(s) for publication purposes whether electronic, print, digital, or electronic publishing via the Internet. Please note: Child(ren) will not be tagged in any images shared on official Mekor Shalom social media accounts.

* I/We agree.

I/We agree.By checking the “I/We Agree” checkbox, I/we hereby commit to cultivating and becoming a part of the fabric of a sacred community where people care about people. We will strive to nurture our neshamot, our souls, as part of our spiritual journey, to grow and evolve Jewishly, and to support the sacred work of Congregation Mekor Shalom.

* Please enter your name(s):

What a blessing to have your household joining Mekor Shalom.
Your presence enhances this community.