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ECC Gateway Membership Application
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Gateway Update Form
Temple Shaaray Tefila welcomes you to our community. Please call (914) 666-3133 if you have any questions or need assistance with this form.
ADULT MEMBER 1
Member 1 - Title
*
Member 1 - First Name
Member 1 - Middle Name
*
Member 1 - Last Name
*
Member 1 - Date of Birth
Member 1 - Cell Phone
*
Member 1 - Email
Member 1 - Occupation
Member 1 - Employer
Member 1 - Business Phone
Member 1 - Business Email
Member 1 - Religion
Member 1 - Hebrew Name
Member 1 - Do you read Hebrew?
Please Select One
Yes
No
ADULT MEMBER 1 - INTERESTS
Adult Learning
Caring Community/helping sick and bereaved
Event Coordination
Facilities and Planning
Finance
Fundraising
Israel
Jewish Observance at the Temple
Jewish Observance in the home
Learning for children
Learning for Teens
Marketting and Communications
Music and Choir
Musical Instruments
Sisterhood/Brotherhood
Social Action
Sustainability
ADULT MEMBER 1 - TALENTS
Bicycling
Computer Skills
Cooking
Dancing
Decorating
Gardening
Graphic Arts
Hiking
Knitting
Mah Jongg
Music
Painting
Photography
Reading
Sewing
Sports
Theatre
Writing
*
Is there a second adult applying for membership?
Please Select One
Yes
No
ADULT MEMBER 2
Member 2 - Title
*
Member 2 - First Name
Member 2 - Middle Name
*
Member 2 - Last Name
*
Member 2 - Date of Birth
Member 2 - Cell Phone
*
Member 2 - Email
Member 2 - Occupation
Member 2 - Employer
Member 2 - Business Phone
Member 2 - Business Email
Member 2 - Religion
Member 2 - Hebrew Name
Member 2 - Do you read Hebrew?
Please Select One
Yes
No
ADULT MEMBER 2 - INTERESTS
Adult Learning
Caring Community/helping sick and bereaved
Event Coordination
Facilities and Planning
Finance
Fundraising
Israel
Jewish Observance at the Temple
Jewish Observance in the home
Learning for children
Learning for Teens
Marketting and Communications
Music and Choir
Musical Instruments
Sisterhood/Brotherhood
Social Action
Sustainability
ADULT MEMBER 2 - TALENTS
Bicycling
Computer Skills
Cooking
Dancing
Decorating
Gardening
Graphic Arts
Hiking
Knitting
Mah Jongg
Music
Painting
Photography
Reading
Sewing
Sports
Theatre
Writing
FAMILY INFORMATION
*
Address
*
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 Code
Home Phone
*
Marital Status
Single
Married
Engaged
Divorced
Widowed
Separated
N/A
Partnered
Anniversary Date
if applicable
CHILD(REN) INFORMATION
*
How many children live with you?
Please Select One
One child
Two children
Three Children
Four children
None
CHILD 1 INFORMATION
*
Child 1 - First Name
Child 1 - Middle Name
*
Child 1 - Last Name
*
Child 1 - Gender
Please Select One
Male
Female
Non-Binary
Prefer not to say
Child 1 - Date of Birth
Child 1 - Hebrew Name
Child 1 - Grade/School or address if not at home:
CHILD 2 INFORMATION
*
Child 2 - First Name
Child 2 - Middle Name
*
Child 2 - Last Name
*
Child 2 - Gender
Please Select One
Male
Female
Non-Binary
Prefer not to say
Child 2 - Date of Birth
Child 2 - Hebrew Name
Child 2 - Grade/School or address if not at home:
CHILD 3 INFORMATION
Child 3 - First Name
Child 3 - Middle Name
Child 3 - Last Name
Child 3 - Gender
Please Select One
Male
Female
Non-Binary
Prefer not to say
*
Child 3 - Date of Birth
Child 3 - Hebrew Name
Child 3 - Grade/School or address if not at home:
CHILD 4 INFORMATION
Child 4 - First Name
Child 4 - Middle Name
Child 4 - Last Name
Child 4 - Gender
Please Select One
Male
Female
Non-Binary
Prefer not to say
Child 4 - Date of Birth
Child 4 - Hebrew Name
Child 4 - Grade/School or address if not at home:
OTHER FAMILY INFORMATION
*
Do any other family members live with you?
Please Select One
No
One other
Two others
Full Name of other family Member
Gender
Please Select One
Male
Female
Non-Binary
Prefer not to say
Date of Birth
Hebrew Name
Full Name of other family Member
Gender
Please Select One
Male
Female
Non-Binary
Prefer not to say
Date of Birth
Hebrew Name
MARRIED CHILD(REN) INFORMATION
*
Do you have any married children?
Please Select One
No
One married child
Two married children
There married children
*
Full Name and age of Child
Spouses Name and age
if applicable
Address
Children's Names
if applicable
*
Full Name and age of Child
Spouses Name and age
if applicable
Address
Children's Names
if applicable
*
Full Name and age of Child
Spouses Name and age
if applicable
Address
Children's Names
if applicable
YAHRZEIT INFORMATION
How many yahrzeits would you like to observe?
Please Select One
None
One yahrzeit
Two Yahrzeits
Three Yahrzeits
Four Yahrzeits
Deceased Name
Related to:
Please Select One
Member 1
Member 2
English Date of Passing
Deceased Name
Related to:
Please Select One
Member 1
Member 2
English Date of Passing
Deceased Name
Related to:
Please Select One
Member 1
Member 2
English Date of Passing
Deceased Name
Related to:
Please Select One
Member 1
Member 2
English Date of Passing
Mon, June 5 2023 16 Sivan 5783
