Special Membership - Form - Ohr HaTorah Synagogue

Please Note:

Each request is treated as an annual, one-time-only request.

Only those who have fulfilled all prior financial obligations to Ohr HaTorah
will be eligible for special membership consideration.

Special membership requests don't include -
Hebrew School Fees or tutoring or Ralph's Community Reswardscontributions.

If your circumstances have changed, please submit a new request for consideration.

If your request is approved, please provide us with a valid credit card and advance written authorization to charge your account for any membership payments.

General Information:

* Membership Status

Please Select OneNew MemberExisting Member

* Marital Status

Please Select OneSingleMarried

* Do you have children?

Please Select OneNoYes

* Are they under 22?

Please Select OneNoYes

Do you financially support your children?

Yes I doNo they're independent

Contact Information:

* Adult 1 - Last Name

* Adult 1 - First Name

* Adult 1 - Date of Birth

Adult 2 - Last Name

Adult 2 - First Name

Adult 2 - Date of Birth

* Address

* City

* Zip Code

* Phone Number

* Primary Email Address

Secondary Email Address

Reason For request:

So that we understand your situation clearly, please set forth in detail the reason(s)
for your special membership request.

* Write Us the Reason For your Request Here:

* Amount I can afford this year:

Prior History:

We know circumstances change.
If you have received special membership consideration in the past,
please indicate the amount of your Tzedakah Commitment in previous years.

2017/18

2018/19

2019/20

Fulfilled Your Pledge?

YesNo

* Date

* Signature of Applicant 1

Signature of Applicant 2