Name on Card: Expiration Date: __ __ /__ __ Card Number: Se

Congregation Kol Ami Membership & Religious School Registration 2015-2016/5776 Name: Please complete the following based on the RATE SHEET for Dues and Tuition Information of Congregation Kol Ami (hereinafter referred to as “the Synagogue”):

Membership Type (select one) Are you a (please select one):  Continuing Member  New Member

 Family

 Single Joint Affiliations, if any:

 Age 30-34  Age 20-29

 Full-Time Student  Chavurah B’Yachad  Other URJ or USCJ synagogue:

 Would like to apply for financial help

Optional Tax-Deductible Donations High Holiday Donations made to the High Holiday Appeal from Appeal Donations July 1 through October 9, 2015 are matched dollar-for-dollar Each donation goes twice as far because it is matched by generous donors*

 I/We would like to support the Synagogue 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 Danny Burman in the Synagogue Main Office

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 for the 2015-2016/5776 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 06/01/2016, 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:  In Full  Quarterly (July, Oct, Jan, April)  Monthly (on the 1st or ______)

Please indicate your donation for the High Holiday Appeal that makes it possible for us to truly be the congregation “for all our people.”

PLEASE REFER TO THE RATE SHEET CalculatIons SYNAGOGUE: Membership Dues ........................ $_________ Mortgage Assessment .................. $_________ Building Fund ................................ $_________ Sisterhood/Kol Amigos ................. $_________ Donation to help a family who is unable to afford dues ............ $_________ High Holiday Appeal to KA ........... $_________ Synagogue Total.............................. $____________

Payment schedule for High Holiday Donation:  In Full  Monthly

RELIGIOUS SCHOOL: Religious School Fees .................. $_________ Payment Type:  Cash or Check  Visa  MC  AmEx  Discover Minus Sibling Discount(s) ............-$(________) $54 p/child in lieu of vol. hrs........... $_________ KAJY Youth Group ...................... $_________ Signature: __________________________________ Today’s Date: _____________ Bar/Bat Mitzvah Fee(s) ................. $_________ This signature affirms that I will make payments as noted above and, if I selected a credit card Donation to help a student who payment, I authorize the Synagogue to charge my credit card (listed below) for any is unable to afford tuition .......... $_________ outstanding balances per the selected payment frequency. Furthermore, this signature affirms my continuing membership in the Synagogue and I authorize the Synagogue to bill me each Religious School Total .................... $____________ fiscal year (July 1-June 30). I will 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 To help defer KA CC Fee 2.5% ....... $______________ date I cancel my membership. The Synagogue will be notify me of any changes in membership GRAND TOTAL ..................$________________ dues. I will immediately notify the Synagogue of any changes in my credit card information. (High Holiday Appeal donations must be paid in full before 10/09/2015).

________________________________________ Expiration Date: __ __ /__ __ Card Number: ________________________ Security Code _______ Billing Zip Code: ________________ Name on Card:

Please note: To protect your confidentiality, the Synagogue 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 Synagogue Finance Office as soon as your card is renewed.



Check here if we may add 2.5% to cover the additional cost to the Synagogue of credit card fees

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Check to receive a confidential application for dues reduction and/or Religious School scholarship rev 07/2015

Rabbi Ilana Schwartzman Cantor Wendy Bat-Sarah

OFFICE PHONE: 801-484-1501 FAX: 801-484-1162 WWW.CONKOLAMI.OR

CONGREGATION KOL AMI 2425 EAST HERITAGE WAY SALT LAKE CITY, UTAH 84109

Congregation Kol Ami Membership & Religious School Registration 2015-2016/5776 Please make any needed entries or corrections to the information on this form. See reverse for donation and payment information. Current mailing address information in the Synagogue’s database:

Corrections to mailing address:

Personal Information (Adults) Unless marked private, contact information will be published in our membership directory

Adult 1

 Private

Adult 2

 Private

First Name: Last Name: Hebrew Name: Date of Birth: Anniversary: Other address if different from mailing address: Phone (home) Phone (cell) Phone (work) Email: Profession: Preferred Communication: Receive Email Announcements: Prefer Quarterly Bulletin: Permission to publish photos Registering for Clubs ($36 each)

 Phone  Email  Yes  No  Electronic  By Mail  Yes  No  Sisterhood  Kol Amigos

 Phone  Email  Yes  No  Electronic  By Mail  Yes  No  Sisterhood  Kol Amigos

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

- If Yes, what program? (see brochure for details)

 TW  Yeladim  K-10  PCDG

 TW  Yeladim  K-10  PCDG

 TW  Yeladim  K-10  PCDG

 TW  Yeladim  K-10  PCDG

- If Yes, are you giving 4 vol. hours or $54 per child?

 4 Vol. Hrs.  $54

 4 Vol. Hrs.  $54

 4 Vol. Hrs.  $54

 4 Vol. Hrs.  $54

3rd-4th gr 5th+ No

3rd-4th gr 5th+ No

3rd-4th gr 5th+ No

3rd-4th gr 5th+ No

 Yes  No

 Yes  No

 Yes  No

 Yes  No

First Name: Last Name: Hebrew Name: Date of Birth Grade as of September 2015 Registering for Religious School:

Registering for KAJY? Bar / Bat Mitzvah between 07/1/2015 and 12/31/2016?

rev 07/2015