Membership Survey 2007

Brith Sholom Kneseth Israel
Membership Survey

Torah. T'fillah. Tikun Olam

Submit by 2/15
Fields marked with an * will be included in a Directory
See opt-out instructions

b = Ben/Bat (insert the Hebrew name of the person's father)
v = (insert the Hebrew name of the person's mother)

Household information:
Adult Member 1:
* Full Name:
Hebrew name:	(Note. Please use English letters even if you know Hebrew)
Son/Daughter of:	b v
Date of Birth:	MM/DD/YYYY
Business Phone:
Occupation:
* Home Address:
* Home Phone:
Email:
Fax:
Cell Phone:
What Year did you join BSKI?
Adult Member 2
Full Name:
Hebrew name:	(Note. Please use English letters even if you know Hebrew)
Son/Daughter of:	b v
Business Phone:
Occupation:
Home Address:
Home Phone:
Email:
Fax:
* Cell phone
What Year did you join BSKI?
Marital Status:
Wedding Anniversary:	MM/DD/YYYY
Children in Household: (There is room for 4 children here - if that is not sufficient, use Comments section below)
Child 1: First name:	Male Female
Middle Name:
Last Name:
Hebrew Name:
Son/Daughter of:	b v
Date of birth:	MM/DD/YYYY
Bar/Bat Mitzvah date:
Child 2: First name:	Male Female
Middle Name:
Last Name:
Hebrew Name:
Son/Daughter of:	b v
Date of birth:	MM/DD/YYYY
Bar/Bat Mitzvah date:
Child 3: First Name:	Male Female
Middle Name:
Last Name:
Hebrew Name:
Son/Daughter of:	b v
Date of birth:	MM/DD/YYYY
Bar/Bat Mitzvah date:
Child 4: First Name:	Male Female
Middle Name:
Last Name:
Hebrew Name:
Son/Daughter of:	b v
Date of birth:	MM/DD/YYYY
Bar/Bat Mitzvah date:
Yahrzeit Information
	Member 1 - First Relative
English Name
Hebrew Name:
Son/Daughter of:	b v
Relationship:
Date of Death:	MM/DD/YYYY
	Member 2 - First Relative
English Name
Hebrew Name:
Son/Daughter of:	b v
Relationship:
Date of Death:	MM/DD/YYYY
	Member 1 - Second Relative
English Name
Hebrew Name:
Son/Daughter of:	b v
Relationship:
Date of Death:	MM/DD/YYYY
	Member 2 -Second Relative
English Name
Hebrew Name:
Son/Daughter of:	b v
Relationship:
Date of Death:	MM/DD/YYYY
Comments:
Do Not Publish the following: (Check all that apply)	Address Phone Number Cell Phone Children's Names Email Addresses Do not include us in the directory
We will NOT* publish children's email addresses*