If you have any questions about how to complete this form, please contact Drew Davis at ddavis@leobaecktemple.org or 310.476.2861 ext 202.

Household Information

Home Address

City

State

Zip Code

Home Phone

Marital Status

Anniversary Date

Personal Information

Member 1

Member 2

Last Name

First Name

Gender - I identify as:

Date of Birth (m/d/y)

Mobile Phone

Email Address

Occupation/Title

Employer

Work Address

Work Telephone

Work Email

Work Telephone

Work Email

Member 1 Retired?

YesNo

Member 2 Retired?

YesNo

If Retired, Former Occupation

Religious Upbringing:

Hebrew names can be entered using English transliteration or in Hebrew using the Hebrew keyboard. (Click on icon at right of each field.)

Hebrew Name

Father's Hebrew Name

Mother's Hebrew Name

Father's Hebrew Name

Mother's Hebrew Name

Medical/Emergency Information

Other (please specify)

Are you a blood donor?

YesNo

Are you a blood donor?

YesNo

If yes, indicate blood type

In case of emergency, the Temple should notify:

Relationship

Phone

FAMILY INFORMATION

Children in your home 25 years old and under

CHILD 1

CHILD 2

CHILD 3

CHILD 4

First Name 1

First Name

Last Name

Hebrew Name

Identifies as:

Date of Birth

Make

Name of School/College

Grade/Year

So that we may better accommodate your child's needs, please indicate any physical limitations:

VEHICLE INFORMATION

Vehicle #1

Vehicle #2

Vehicle #3

Vehicle #4

Make

Model

Year

Color

License Plate #

YAHRZEIT INFORMATION

I/We prefer annual reminders by (please select one):

Please Select OneGregorian Date (Secular)Hebrew Date*

*Simply give us the Gregorian (secular) month, date, and year, and we will convert it to the Hebrew date (Ex: June 30, 2000).

Full English Name

Observed by (member's name)

Relationship

Yahrzeit Date

Full English Name

Observed by (member's name)

Relationship

Yahrzeit Date

Full English Name

Observed by (member's name)

Relationship

Yahrzeit Date

Full English Name

Observed by (member's name)

Relationship

Yahrzeit Date

Full English Name

Observed by (member's name)

Relationship

Yahrzeit Date

Full English Name

Observed by (member's name)

Relationship

Yahrzeit Date

INTERESTS

Involvement in Temple life will enhance your experience at Leo Baeck Temple. Please indicate your interest by checking any and all of the following areas:

COMMUNITY COMMITMENT

Sustaining Tzedek at LBT

The Talmud teaches “Kol Yisrael arevim zeh b’zeh” – “all Jews are responsible for one another.” In keeping with that value, Leo Baeck Temple has long embraced the conviction that members who are financially able should be counted upon to help those of our members who are less able to afford membership. Sustaining Tzedek at LBT maintains our egalitarian community, where no one is denied the opportunities of temple membership because of monetary difficulties. Please consider joining this group willing to fulfill the mitzvah of tzedakah by pledging an amount in addition to your standard membership commitment.

I/We would like to fulfill the mizvah of tzedakah by pledging the following amount, in addition to our standard membership contribution:

Suggested donation levels: $18,000, $13,000, $10,000, $5,000, $3,500, $1,500, $720, $360 (enter amount)

ARZA Membership
ARZA: the mission of ARZA is to further progressive Judaism in Israel. The Temple encourages all members to join ARZA.

Dues are $50 per year (enter amount, if applicable)

ARZA Membership

Total

Please charge all fees to my credit card until further notice.

Community Commitment Form 2022-23

Household Information

Personal Information

Medical/Emergency Information

FAMILY INFORMATION

VEHICLE INFORMATION

YAHRZEIT INFORMATION

INTERESTS

COMMUNITY COMMITMENT

Once you have completed the form above in full, click on the submit button to be redirected to the payment information page.