Name on Card: Expiration Date: __ __ /__ __ Card Number: Secu
Congregation Kol Ami Membership Registration 2016-2017/5777 Membership Type (select one) Are you a (please select one): Continuing Member New Member
Name________________________________________________________
Please complete the following based on the “Dues and Tuition Information” brochure:
Family
Single Joint Affiliations, if any:
Age 30-34 Age 20-29
Student B’Yachad Chavurah
Other URJ or USCJ synagogue: ____________________________
Optional Tax-Deductible Donations High Holiday Donations made to the High Holiday Appeal from Appeal Donations July 1 through October 27, 2016 are matched dollar-for-dollar Each donation goes twice as far because it is matched by generous donors*
I/We would like to support Kol Ami through the High Holiday Appeal: I/We would like to support the Religious School through the HHD Appeal:
$_________ $_________
* I/We would like to become a matching angel – please call me
Religious School Donation Discount
I/We would like to donate the “sibling discount” to the Religious School ($25/child for 2 or more children)
Payment Information Please complete the box to the right to calculate Membership, Mortgage Assessment, Building Fund, Sisterhood/Kol Amigos, Religious School, KAJY, B’nai Mitzvah Fees, and for Donations. NOTE: All payments must be completed on or before 06/30/2017, except for High Holiday Appeal and B’nai Mitzvah Fees, which are customized by date of the event; the office will contact you about B’nai Mitzvah payments). Club dues are paid in first scheduled payment.
Payment schedule for dues, Religious School fees, and other fees: st
In Full Quarterly (July, Oct, Jan, April) Monthly (on the 1 or ______)
Total Amount Due Calculations SYNAGOGUE: Membership Dues ................ $_________ Mortgage Assessment ......... $_________ Building Fund ......................... $_________
Please indicate your donation for the High Holiday Appeal that makes it
Sisterhood/Kol Amigos ....... $_________
possible for us to truly be the congregation “for all our people.”
High Holiday Appeal ............ $_________
Payment schedule for High Holiday Donation: In Full Monthly
Membership Scholarship .... $_________
(High Holiday Appeal donations must be paid in full before 10/27/2016).
SYNAGOGUE TOTAL ..... $__________
Payment Type:
Cash or Check
Visa
MC
AmEx
Discover
Signature: __________________________________ Today’s Date: _____________ This signature affirms that I will make payments as noted above, and if I selected a credit card payment, authorize Kol Ami to charge my credit card (listed below) for any outstanding balances per the selected payment frequency. Furthermore, this signature affirms my continuing membership in Congregation Kol Ami; Kol Ami will bill me each fiscal year (July 1-June 30) and it is my responsibility to notify the synagogue if I wish to end my membership or change my payment method. Per this agreement, I am responsible for paying all dues up to the date I cancel my membership. Members will be notified about changes in membership dues.
RELIGIOUS SCHOOL: Religious School Total (from Rel. Sch. form) ....... $_________ OTHER To defer CC 2.5% Fee ......... $_________
TOTAL ............. $______________
_______________________________________ Expiration Date: __ __ /__ __ Card Number: _______________________ Security Code _______ Billing Zip Code: ________________ Name on Card:
Please note: To protect your confidentiality, Kol Ami does not store credit card numbers after they have been entered into the payment processing system. Please enter the current credit card you would like to use for your payment, and please be sure it does not expire prior to end of your payment schedule. If this is not possible, please provide a current card to the billing office as soon as your card is renewed.
Check here if we may add 2.5% to cover the additional cost to Kol Ami of credit card fees Check to receive a confidential application for dues reduction and/or Religious School scholarship upd 05/2016
Congregation Kol Ami Membership Registration 2016-2017
CONGREGATION KOL AMI 2425 EAST HERITAGE WAY SALT LAKE CITY, UTAH 84109
OFFICE PHONE: 801-484-1501 FAX: 801-484-1162 WWW.CONKOLAMI.ORG
Please make any needed entries or corrections to the information on this form. See reverse for donation and payment information. Current mailing address:
Personal Information (Adults) Unless marked private, contact information will be published in our membership directory
Adult 1
Adult 2
Private
Private
First Name: Last Name:
Yes No
I am Jewish::
Yes No
Hebrew Name: If you do not have a Hebrew name, the Rabbi can help you chose one.
Date of Birth: Anniversary: Other address if different from mailing address: Phone (home) Phone (cell) Phone (work) Email: Profession: Preferred Communication:
Phone Email
Phone Email
Receive Email Announcements:
Yes No
Yes No
Prefer Quarterly Bulletin:
Electronic By Mail
Electronic By Mail
Permission to publish photos
Yes No
Yes No
Registering for Clubs ($36 each)
Sisterhood Kol Amigos
Sisterhood Kol Amigos
PLEASE GO ONLINE TO LIST YOUR YAHRZEITS.
Personal Information (All Dependent Children) Children’s information is not published in our Synagogue membership directory
Child 1
Child 2
Child 3
Child 4
Yes No
Yes No
Yes No
Yes No
First Name: Last Name: Hebrew Name: Date of Birth Grade as of Sept. 2016 Registering for Religious School:
IF YES, PLEASE FILL OUT SEPARATE RELIGIOUS SCHOOL & YOUTH DEPARTMENT FORM
upd 05/2016
Name________________________________________________________
Please complete the following based on the “Dues and Tuition Information” brochure:
Family
Single Joint Affiliations, if any:
Age 30-34 Age 20-29
Student B’Yachad Chavurah
Other URJ or USCJ synagogue: ____________________________
Optional Tax-Deductible Donations High Holiday Donations made to the High Holiday Appeal from Appeal Donations July 1 through October 27, 2016 are matched dollar-for-dollar Each donation goes twice as far because it is matched by generous donors*
I/We would like to support Kol Ami through the High Holiday Appeal: I/We would like to support the Religious School through the HHD Appeal:
$_________ $_________
* I/We would like to become a matching angel – please call me
Religious School Donation Discount
I/We would like to donate the “sibling discount” to the Religious School ($25/child for 2 or more children)
Payment Information Please complete the box to the right to calculate Membership, Mortgage Assessment, Building Fund, Sisterhood/Kol Amigos, Religious School, KAJY, B’nai Mitzvah Fees, and for Donations. NOTE: All payments must be completed on or before 06/30/2017, except for High Holiday Appeal and B’nai Mitzvah Fees, which are customized by date of the event; the office will contact you about B’nai Mitzvah payments). Club dues are paid in first scheduled payment.
Payment schedule for dues, Religious School fees, and other fees: st
In Full Quarterly (July, Oct, Jan, April) Monthly (on the 1 or ______)
Total Amount Due Calculations SYNAGOGUE: Membership Dues ................ $_________ Mortgage Assessment ......... $_________ Building Fund ......................... $_________
Please indicate your donation for the High Holiday Appeal that makes it
Sisterhood/Kol Amigos ....... $_________
possible for us to truly be the congregation “for all our people.”
High Holiday Appeal ............ $_________
Payment schedule for High Holiday Donation: In Full Monthly
Membership Scholarship .... $_________
(High Holiday Appeal donations must be paid in full before 10/27/2016).
SYNAGOGUE TOTAL ..... $__________
Payment Type:
Cash or Check
Visa
MC
AmEx
Discover
Signature: __________________________________ Today’s Date: _____________ This signature affirms that I will make payments as noted above, and if I selected a credit card payment, authorize Kol Ami to charge my credit card (listed below) for any outstanding balances per the selected payment frequency. Furthermore, this signature affirms my continuing membership in Congregation Kol Ami; Kol Ami will bill me each fiscal year (July 1-June 30) and it is my responsibility to notify the synagogue if I wish to end my membership or change my payment method. Per this agreement, I am responsible for paying all dues up to the date I cancel my membership. Members will be notified about changes in membership dues.
RELIGIOUS SCHOOL: Religious School Total (from Rel. Sch. form) ....... $_________ OTHER To defer CC 2.5% Fee ......... $_________
TOTAL ............. $______________
_______________________________________ Expiration Date: __ __ /__ __ Card Number: _______________________ Security Code _______ Billing Zip Code: ________________ Name on Card:
Please note: To protect your confidentiality, Kol Ami does not store credit card numbers after they have been entered into the payment processing system. Please enter the current credit card you would like to use for your payment, and please be sure it does not expire prior to end of your payment schedule. If this is not possible, please provide a current card to the billing office as soon as your card is renewed.
Check here if we may add 2.5% to cover the additional cost to Kol Ami of credit card fees Check to receive a confidential application for dues reduction and/or Religious School scholarship upd 05/2016
Congregation Kol Ami Membership Registration 2016-2017
CONGREGATION KOL AMI 2425 EAST HERITAGE WAY SALT LAKE CITY, UTAH 84109
OFFICE PHONE: 801-484-1501 FAX: 801-484-1162 WWW.CONKOLAMI.ORG
Please make any needed entries or corrections to the information on this form. See reverse for donation and payment information. Current mailing address:
Personal Information (Adults) Unless marked private, contact information will be published in our membership directory
Adult 1
Adult 2
Private
Private
First Name: Last Name:
Yes No
I am Jewish::
Yes No
Hebrew Name: If you do not have a Hebrew name, the Rabbi can help you chose one.
Date of Birth: Anniversary: Other address if different from mailing address: Phone (home) Phone (cell) Phone (work) Email: Profession: Preferred Communication:
Phone Email
Phone Email
Receive Email Announcements:
Yes No
Yes No
Prefer Quarterly Bulletin:
Electronic By Mail
Electronic By Mail
Permission to publish photos
Yes No
Yes No
Registering for Clubs ($36 each)
Sisterhood Kol Amigos
Sisterhood Kol Amigos
PLEASE GO ONLINE TO LIST YOUR YAHRZEITS.
Personal Information (All Dependent Children) Children’s information is not published in our Synagogue membership directory
Child 1
Child 2
Child 3
Child 4
Yes No
Yes No
Yes No
Yes No
First Name: Last Name: Hebrew Name: Date of Birth Grade as of Sept. 2016 Registering for Religious School:
IF YES, PLEASE FILL OUT SEPARATE RELIGIOUS SCHOOL & YOUTH DEPARTMENT FORM
upd 05/2016
