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1
Application date______________
Welcome to the Brooklyn Heights Synagogue. We are delighted that you have chosen to become part of our community. We hope that you will find
membership an enriching experience and encourage you to explore the diverse opportunities for Jewish expression that BHS offers. Please call upon
our clergy, staff, and lay leaders whenever we can assist you in becoming part of our community. All information in this application will be treated
confidentially.
PLEASE PRINT CLEARLY OR SUBMIT ELECTRONICALLY VIA OUR WEBSITE, www.bhsbrooklyn.org/join-us
ADULT 1
Male Female
ADULT 2
Male Female
Full name and middle initial
Nickname (if applicable)
Personal Status
If you are married, please make sure to fill
in your anniversary date to the right.
Single Married Widowed
Anniversary Date _________________________
Partnered Divorced
Other _______________________________
Hebrew Name (if known)
Date of Birth
Birthplace
Are you new to the Brooklyn Heights area?
If so, what is your former city and state of
residence?
Do you our any member of your family
require special accommodations?
How would you like your name(s) to appear on our mailings? We will do our best to accommodate your request within system capabilities.
Name(s): _______________________________________________________________________________________________
Home address: __________________________________________________________________________________
City: _________________________________________________________ State: __________________ Zip: ____________
Phone: ____________________________________________ Fax: _______________________________________________
Cell Phone Adult 1: __________________________________ Cell Phone Adult 2: _____________________________________
Most of our communications are sent by email. Please be sure to give us an address that
you check regularly or tick the box below if you do not use email.
Email Adult 1: _________________________________________ Email Adult 2:________________________________________
I do not use email. Please mail all correspondence. I do not use email. Please mail all correspondence.
Our family wants to save trees! Please email all correspondence.
Personal Information
Contact Information
Brooklyn Heights Synagogue
MEMBERSHIP APPLICATION
131 Remsen Street
Brooklyn NY 11201
Adult 1
Adult 2
Religious background in which you were
raised
Reform Conservative
Orthodox Jewish unaffiliated
Please specify if you were not raised
Jewish: _____________________________
Reform Conservative
Orthodox Jewish unaffiliated
Please specify if you were not raised
Jewish: _____________________________
If you became Jewish as an adult
Date, Congregation, City
Bar/Bat Mitzvah (if applicable)
Date, Congregation, City
Confirmation (if applicable)
Date, Congregation, City
Have you ever been a member of another
synagogue (as an adult)? If so, when?
Congregation most recently or currently
affiliated with
Please list any relatives or friends who are
BHS members
Adult 1
Adult 2
Occupation/Title
Area of specialization (Example: if law,
what area? If medical, what field?)
Employer
Address
City, State, Zip
Business Phone
Business Fax
Name
Hebrew Name
Relationship
To Member
Date of Death
Before or After
Sundown?
Remembered by
common calendar
or Hebrew date?
Should you have additional Yahrzeit, please email the office at office@bhsbrooklyn.org.
Please send me information about memorial plaques at BHS. Please send me information about the BHS Cemetery.
Religious Background
Business Information
Yahrzeit Information
Child 1
Male Female
Child 2
Male Female
Child 3
Male Female
Child 4
Male Female
First and middle name
Last name
Hebrew name
(if known)
Birth date
Address
(if not living with you)
Marital status
Single
Married
Partnered
Single
Married
Partnered
Single
Married
Partnered
Single
Married
Partnered
Is this child being raised
in the Jewish faith?
Yes No
Yes No
Yes No
Yes No
Will this child be
attending Religious
School at BHS?
Yes No
Yes No
Yes No
Yes No
Bar/Bat Mitzvah:
Date, Congregation, City
Confirmation:
Date, Congregation, City
If previously attended
Religious School, list
Congregation and City
Name of secular school,
school address, and
current grade
If you have more than four children, please attach an additional page.
Adult 1 Emergency Contact Name: _______________________________________________
Phone: ________________________________ Relationship: __________________________
Address: __________________________________ City: ______________ State: __________
Dr. Name & Phone: ___________________________________________________________
Health Care Proxy: _____________________________________________________________
Adult 2 Emergency contact Name: _______________________________________________
Phone: ________________________________ Relationship: __________________________
Address: __________________________________ City: ______________ State: __________
Dr. Name & Phone: ___________________________________________________________
Health Care Proxy: _____________________________________________________________
Children’s Information
Emergency Contact Information
At the Brooklyn Heights Synagogue, we encourage our congregants to become involved in many aspects of life in our congregational
community. In furthering this ideal, we request that upon signing this application you commit to participate in congregational life.
Please indicate which of these areas interest you by checking the appropriate box or boxes. Your participation will help strengthen the
community and will make your BHS experience more meaningful.
For more detailed information on the options below, please visit our website, www.bhsbrooklyn.org
Adult Education Classes Gift Shop Volunteer Preschool Arena
Assisting with office work Holiday Celebrations Religious School Involvement
Book Group and Arts Events Israel Engagement Sisterhood
Chesed Caring/Social Action Membership Programs & Activities Homeless Shelter Volunteer
Fund Raising Events and Programs Newsletter Writing Worship
Youth Group Activities
Tell us more! What are your passions? What are your interests? How do you see yourself and your family becoming engaged in
Synagogue life? Would you like to start a new committee or program? If so, please contact office@bhsbrooklyn.org
PLEASE SUBMIT A FAMILY PICTURE WITH YOUR MEMBERSHIP APPLICATION AND IDENTIFY EACH FAMILY MEMBER.
Adult 1: I (PLEASE PRINT NAME), ________________________________, am applying to become a member of Brooklyn Heights
Synagogue. Signature_____________________________________________________ Date________________
Adult 2: I (PLEASE PRINT NAME), ________________________________, am applying to become a member of Brooklyn Heights
Synagogue. Signature_____________________________________________________ Date________________
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
For Synagogue Office use only
Date of membership: __________________________________
Membership category: _________________________________
Opportunity for Participation
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Completed 22 March 2022

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