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Prospective Member Form
Please verify reCaptcha before submitting the form.
If you are filling out this form on behalf of a family member or friend, you must LOG OUT of your
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Household Information: Prospective Member 1
*
First Name
*
Last Name
*
Birth Date
Gender Identity
N/A or Unknown
Male
Female
*
Email
*
Mobile Phone
*
Address
(Apt, Suite, etc.)
*
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
*
Is there a second adult in the household?
Please Select One
Yes
No
Household Information: Prospective Member 2
First Name
Last Name
Birth Date
Gender Identity
N/A or Unknown
Male
Female
Email
Mobile Phone
Additional Information
*
Do you have children under 25 living in your household?
Please Select One
Yes
No
Children
Please provide the name and birth date of each child
Are you interested in enrolling your children in the following for the current or upcoming school year?
Amy Gail Buchman Preschool (Toddler through Pre-K)
Flom Religious School (Pre-K through 12th grade)
Not applicable
*
Do you have a relative who is a current member of Congregation Schaarai Zedek?
Please Select One
Yes
No
Are you currently a member of another congregation?
Please Select One
Yes
No
Former Congregation Name & Location
Current Congregation Name & Location
Have you already spoken to a staff member about joining Schaarai Zedek?
Please Select One
Yes
No
How did you hear about us?
Live streaming services
Google
Personal recommendation
Attended a life cycle event (bar/bat mitzvah, wedding funeral, etc.)
Used to be a member
Other
Is there anything more you'd like to tell us about why you're interested in joining Schaarai Zedek?
Thank you for submitting your prospective member form. We'll review it and follow up with you soon. If you have any questions, please reach out to Debra Zepeda at
dzepeda@zedek.org
.
Fri, May 9 2025 11 Iyar 5785
