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Hazzan Sered-Lever
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Mekor Shalom Membership Connections Form
Please verify reCaptcha before submitting the form.
Dear Friends,
What draws each of us into a community?
I believe that a desire to connect plays a large role in what brings us into a community. Each one of us deserves to feel a connection to those around us, to feel a sense of belonging. Each one of us deserves to feel a connection to God and to the teachings of our tradition.
It is with this in mind that I am delighted that you are interested in Congregation Mekor Shalom. Mekor Shalom means Source of Peace. Mekor Shalom is a community where each person matters — your presence, your feelings, and your neshama (your soul). At Mekor Shalom, each of us is welcomed and celebrated for who we are.
I want to invite you to become a part of this sacred community. The weaving of the presence of each person into the communal tapestry is a blessing. Having your uniquely beautiful colors as a part of the tapestry will enrich and enhance Mekor Shalom infinitely. Each one of us has the unlimited potential to be a source of peace for ourselves and for the entire community.
Please feel free to
contact me
with any questions, comments, concerns, or ideas.
May God, the Source of Peace and Source of all Creation, guide us on this spiritual journey of connection.
B’shalom,
Hazzan Jodi M. Sered-Lever,
Founding Spiritual Leader
Adult #1
*
Title:
Please Select One
Mx.
Mr.
Ms.
Mrs.
Rabbi
Hazzan
Dr.
Prof.
The Hon.
Col.
Chaplain
No Title
*
Last Name:
*
First Name:
Middle Name:
*
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:
*
Email address:
*
Preferred phone number:
*
Is this phone number is a mobile number?
Please Select One
Yes
No
Please check here if you would like to be listed in the member directory.
Gender Identity:
Pronouns:
Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination)
Date-of-Birth:
*
Please indicate whether you are:
Jewish by Birth
Jewish by Choice
a Supportive Partner/Spouse
Hebrew Name (First & Middle, if applicable):
English or Hebrew letters may be entered in the name fields.
Hebrew Name of Parent (if applicable):
Hebrew Name of Parent (if applicable):
Please indicate, if applicable, whether you are a:
Kohen
Levi
Yisrael
I don't know.
If you aren't sure, that's fine
!
Relationship Status (if applicable):
Single
Partnered
Married
Engaged
Widowed
Divorced
Separated
Wedding anniversary date (if applicable):
Occupation(s) or retired (If retired, please share your professional field, e.g. retired accountant or retired physicist):
If need be, may Mekor Shalom contact you at work?
Yes
No
Not applicable
If yes, work number is:
Please check any teams/activities that may be of interest to you:
Adult Lifelong Learning Team (involvement with aspects of the adult education program)
Adult Lifelong Learning: Teaching a class
Adult Lifelong Learning: Taking a class
Community Involvement Team (organizes social action programs and projects)
Financial Stewardship/Endowment Team
Fundraising Team (organizes congregational fundraising activities)
Kiddush Team (organizes weekly Shabbat morning fellowship refreshments)
Look Who's Coming to Shabbat Team (organizes occasional, congregational Shabbat meals)
Mekor Tikvah (Source of Hope) Team (supporting Mekor Shalom friends during times of need)
Membership Team: Outreach to new members
Membership Team: Welcoming new members
Membership Team: Membership retention
Oneg Team (organizes weekly Friday night fellowship refreshments)
Staying Connected Team (organizes congregational social programs)
Youth Activities Team (helps facilitate the Mekor Shalom youth program)
Ideas and suggestions to share:
Adult #2
Title:
Mx.
Mr.
Ms.
Mrs.
Rabbi
Hazzan
Dr.
Prof.
The Hon.
Col.
Chaplain
No Title
Last Name:
First Name:
Middle Name:
Address, if different from Adult #1:
Email address:
Preferred phone number:
Is this phone number is a mobile number?
Yes
No
Please check here if you would like to be listed in the member directory.
Gender Identity:
Pronouns:
Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination)
Date-of-Birth:
Please indicate whether you are:
Jewish by Birth
Jewish by Choice
a Supportive Partner/Spouse
Hebrew Name (First & Middle, if applicable):
English or Hebrew letters may be entered in the name fields.
Hebrew Name of Parent (if applicable):
Hebrew Name of Parent (if applicable):
Please indicate, if applicable, whether you are a:
Kohen
Levi
Yisrael
I don't know.
If you aren't sure, that's fine
!
Relationship Status:
Single
Partnered
Married
Engaged
Widowed
Divorced
Separated
Wedding anniversary date (if applicable):
Occupation(s) or retired (If retired, please share your professional field, e.g. retired accountant or retired physicist):
If need be, may Mekor Shalom contact you at work (if applicable)?
Yes
No
Not applicable
If yes, work number is:
Please check any teams/activities that may be of interest to you:
Adult Lifelong Learning Team (involvement with aspects of the adult education program)
Adult Lifelong Learning: Teaching a class
Adult Lifelong Learning: Taking a class
Community Involvement Team (organizes social action programs and projects)
Financial Stewardship/Endowment Team
Fundraising Team (organizes congregational fundraising activities)
Kiddush Team (organizes weekly Shabbat morning fellowship refreshments)
Look Who's Coming to Shabbat Team (organizes occasional, congregational Shabbat meals)
Mekor Tikvah (Source of Hope) Team (supporting Mekor Shalom friends during times of need)
Membership Team: Outreach to new members
Membership Team: Welcoming new members
Membership Team: Membership retention
Oneg Team (organizes weekly Friday night fellowship refreshments)
Staying Connected Team (organizes congregational social programs)
Youth Activities Team (helps facilitate the Mekor Shalom youth program)
Ideas and suggestions to share:
Dependent Children & Dependent Adults
Child or Dependent Adult #1
Last Name:
First Name:
Middle Name:
Gender Identity:
Pronouns:
Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination)
Date-of-Birth:
Hebrew Name (First & Middle, if applicable):
English or Hebrew letters may be entered in the name fields.
Parent #1's Hebrew Name (if applicable):
Parent #2's Hebrew Name (if applicable):
Email address (if applicable):
Cell phone number (if applicable)
Religious Education Plan (for school age children):
Mekor Shalom Religious School
Hillel Academy
Alternative
Not applicable
Areas of Interest:
Read Torah
Lead Services
Youth Group
Teen Classes
College Student Care Packages
Child or Dependent Adult #2
Last Name
First Name
Middle Name:
Gender Identity:
Pronouns:
Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination)
Date-of-Birth:
Hebrew Name (First & Middle, if applicable):
English or Hebrew letters may be entered in the name fields.
Parent #1's Hebrew Name (if applicable):
Parent #2's Hebrew Name (if applicable):
Email address (if applicable):
Cell phone number (if applicable)
Religious Education Plan (for school age children):
Mekor Shalom Religious School
Hillel Academy
Alternative
Not applicable
Areas of Interest:
Read Torah
Lead Services
Youth Group
Teen Classes
College Student Care Packages
Child or Dependent Adult #3
Last Name
First Name
Middle Name:
Gender Identity:
Pronouns:
Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination)
Date-of-Birth:
Hebrew Name (First & Middle, if applicable):
English or Hebrew letters may be entered in the name fields.
Parent #1's Hebrew Name (if applicable):
Parent #2's Hebrew Name (if applicable):
Email address (if applicable):
Cell phone number (if applicable)
Religious Education Plan (for school age children):
Mekor Shalom Religious School
Hillel Academy
Alternative
Not applicable
Areas of Interest:
Read Torah
Lead Services
Youth Group
Teen Classes
College Student Care Packages
Child or Dependent Adult #4
Last Name
First Name
Middle Name:
Gender Identity:
Pronouns:
Please indicate (e.g. She/Her/Hers, He/Him/His, They/Them/Theirs, a combination)
Date-of-Birth:
Hebrew Name (First & Middle, if applicable):
English or Hebrew letters may be entered in the name fields.
Parent #1's Hebrew Name (if applicable):
Parent #2's Hebrew Name (if applicable):
Email address (if applicable):
Cell phone number (if applicable)
Religious Education Plan (for school age children):
Mekor Shalom Religious School
Hillel Academy
Alternative
Not applicable
Date-of-Birth:
Remembering Loved Ones Who Have Died: Yahrzeit Information
First Name
Last Name
Relationship to (e.g. parent of):
English Date of Death:
Death Occurred before Sundown:
Please indicate yes or no.
Hebrew Date of Death (if known):
First Name
Last Name
Relationship to (e.g. parent of):
English Date of Death:
Death Occurred before Sundown:
Please indicate yes or no.
Hebrew Date of Death (if known):
First Name
Last Name
Relationship to (e.g. parent of):
English Date of Death:
Death Occurred before Sundown:
Please indicate yes or no.
Hebrew Date of Death (if known):
First Name
Last Name
Relationship to (e.g. parent of):
English Date of Death:
Death Occurred before Sundown:
Please indicate yes or no.
Hebrew Date of Death (if known):
Additional Yahrzeit Names and Information (if applicable):
Name:
Relationship:
Best Contact Phone Number:
Name:
Relationship:
Best Contact Phone Number:
Name:
Relationship:
Best Contact Phone Number:
A Request for Photographs:
Please Select One
I/we agree.
I/we do not agree.
I/we give permission to Congregation Mekor Shalom to photograph our household members, including child(ren) if applicable, to use image(s) for publication purposes whether electronic, print, digital, or electronic publishing via the Internet. Please note: Child(ren) will not be tagged in any images shared on official Mekor Shalom social media accounts.
*
I/We agree.
I/We agree.
By checking the “I/We Agree” checkbox, I/we hereby commit to cultivating and becoming a part of the fabric of a sacred community where people care about people. We will strive to nurture our
neshamot
, our souls, as part of our spiritual journey, to grow and evolve Jewishly, and to support the sacred work of Congregation Mekor Shalom.
*
Please enter your name(s):
What a blessing to have your household joining Mekor Shalom.
Your presence enhances this community.
Sat, December 21 2024 20 Kislev 5785
