2023 -24 Membership Commitment Form

We are delighted you have chosen to be part of the Emanuel community for another year (and hopefully many more). We welcome all who wish to join us!

If you are interested in a synagogue that prides itself on being open, genuine and inclusive; if you want a place to explore and find your own place as someone - who identifies as a Jew , is in a Jewish family or considering/in the process of becoming a Jew- in the 21st Century; if you're looking for a great group of people who care and support each other, Emanuel is the right community for you.

Email address

Below is a list of our membership commitment for the current fiscal year. It currently cost Emanuel $4200 per membership to sustain our congregation and we are proud to continue to offer dues relief to those who can not afford their full dues. Therefore, every dollar you can contribute truly helps our community. If you would like to help a member/family that is unable to pay full dues, please take a moment to complete the Benefactor section of this renewal form.

Single Young (<36): $500
Young Couple (<36): $1,300
Single Adult / Single Parent Family: $1,850
Couple / Family: $3,400
Senior Single: $1,625
Senior Couple (65+): $2,500

Please note, your account will have a Security Fee of $350 and a Building Fee of $300 (150 for members who have been part of Emanuel for over 6 consecutive years).

Please select the Membership Category that fits your family. If you require Dues Relief or are a entering your second year of membership, please select that option and you will be asked two additional questions.

Additional Building Fee

This is an additional fee to help Emanuel maintain the building and grounds.

Additional Security Fee (Required)

This is an additional fee to help Emanuel maintain security measures to keep our community safe.

My family can contribute the follow amount for membership for FY24 (July 2023 - June 2024)

If you would like to become a benefactor, helping members/family that can not afford full dues, please select an amount below to contribute. Thank you for your consideration and support.

PERSONAL INFORMATION

Adult 1 Information

First Name

Middle Name

Last Name

Correspondence Email Address

Birth date

Occupation

Hobbies

Hebrew Name

Father's Hebrew Name

Mother's Hebrew Name

Community Involvement

Please indicate any areas of talent/interest by checking the appropriate box or boxes.

Adult 2 Information

First Name

Middle Name

Last Name

Correspondence Email Address

Date of Birth

Occupation

Hobbies/Interests

Hebrew Name

Father's Hebrew Name

Mother's Hebrew Name

Community Involvement

Please indicate any areas of talent/interest by checking the appropriate box or boxes.

Please send all communication to:

Adult 1Adult 2Please opt us out from receiving emails from Emanuel Congregation

Would you be interested in auto-renewing membership at Emanuel?

Yes! I would like to be able to auto-renew for 3 years!Yes! I would like to be able to auto-renew for 5 years!No thank you! I like being able to renew my membership every year!

How many children will be included in your Membership/Registration?

noneOne ChildTwo ChildrenThree ChildrenFour Children

Please include the names of all your children under the age of 25 as they are included in your membership. Children 26 and older must apply for membership on their own.

Child 1

First Name

Middle Name

Last Name

Hebrew Name

Date of Birth

Name of School Entering in the Fall

Grade Entering in the Fall

What are you child's pronouns?

Child 2

First Name

Middle Name

Last Name

Hebrew Name

Date of Birth

Name of School Entering in the Fall

Grade Entering in the Fall

What are you child's pronouns?

Child 3

Child 3 First Name

Child 3 Middle Name

Child 3 Last Name

Hebrew Name

Date of Birth

Name of School Entering in the Fall

Grade Entering in the Fall

What are you child's pronouns?

Child 4

First Name

Middle Name

Last Name

Hebrew Name

Date of Birth

Name of School Entering in the Fall

Grade Entering in the Fall

What are you child's pronouns?

Fund For Emanuel

The Fund for Emanuel is an unrestricted fund. For example, it is not designated for (restricted to) building repairs, travel and transportation, and/or library books.

The Fund for Emanuel is used where funds are needed most. It supports our streaming efforts during servicesa nd events, our growing youth group and teen programming, online speaker series and study groups, social justice initiatives, High Holy Day production, upcoming virtual Share Shabbat, and so much more.

It opens our doors, real and virtual, to all who seek richer, more meaningful lives.

Emanuel Congregation is your neighborhood congregation, wherever you live, and we are grateful you are here.

Please support Emanuel with a gift to our Fund for Emanuel

Thank you & Todah Rabah
For additional questions about donations please contact the Emanuel office: 773-561-5173

General Donation to Help the Emanuel Community

I would like to make a gift to Emanuel.

EDUCATIONAL CONSIDERATIONS

In the text box(es) below, please note if your child(ren) receive(s) any education services, such as IEP, Adaptive Equipment, Special Education, Outside Tutoring, Physical / Occupational Therapy, One-on-on Aide*, Behavioral Resource, Gifted/Talented, etc.

Student 1

Student 2

Student 3

Student 4

Is there anything else you would like us to know about your child(ren)?

DIAGNOSES OR ASSESSMENTS

In the text box(es) below, please note if your child(ren) is/are diagnosed as having, or is being assessed for any of the following: ADHD, Anxiety, Autism Spectrum Disorder, Conduct/Oppositional Disorder, Developmental/Cognitive Delay, Depression, Emotional/Behavioral Disorder, Hearing Disorder, Learning Disability, Obsessive Compulsive Disorder (OCD), Speech/Language Disability, Physical Disability, Cerebral Palsy, Tourette Syndrome, Visual Impairment, Other.

Student 1

Student 2

Student 3

Student 4

MEDICAL INFORMATION

Student 1 OHIP Number

Student 2 OHIP Number

Student 3 OHIP Number

Student 4 OHIP Number

Are student 1 immunizations current?

NoYes

Are student 2 immunizations current?

NoYes

Are student 3 immunizations current?

NoYes

Are student 4 immunizations current?

NoYes

Does student 1 take medication on a regular basis?

NoYes

Does student 2 take medication on a regular basis?

NoYes

Does student 3 take medication on a regular basis?

NoYes

Does student 4 take medication on a regular basis?

NoYes

Student 1 - Please enter any additional information regarding medical conditions (please include triggers, severity, and treatment)

Student 2 - Please enter any additional information regarding medical conditions (please include triggers, severity, and treatment)

Student 3 - Please enter any additional information regarding medical conditions (please include triggers, severity, and treatment)

Student 4 - Please enter any additional information regarding medical conditions (please include triggers, severity, and treatment)

Family Publicity Permission

By clicking yes, you are agreeing that Student's photograph, name, art, written work, voice or verbal statements may appear in Emanuel Congregation publicity or publications.

Nut Awareness Policy

We have a number of students who suffer from severe nut allergies. Even trace amounts of a problem food can cause a life-threatening allergic reaction.

Please help us maintain a safe community by keeping all nuts and nut products out of the school (peanuts, walnuts, almonds and all other tree nuts). Even those foods labeled with “may contain" or "traces of" in the list of ingredients can be harmful. We appreciate your assistance in making the school safe for every student.

While we strive to be a nut aware facility, we cannot guarantee that your child will not come into contact with products containing nuts. Every reasonable effort will be made to provide a nut aware environment at Emanuel Congregation. Our Staff, members, and students cannot be held responsible. The ultimate responsibility lies with the parents and student to ensure their safety. It is therefore important that if your child has serious allergies, inform us upon registration, and provide any necessary instructions and an EpiPen.

EMERGENCY CONTACT INFORMATION

Please list two people that we may contact in the event we are unable to reach a parent in an emergency.

Who is allowed to pick up your child(ren) from school?

Please enter one or more names of people you authorize to pick up your child(ren) after school.

Emergency Contact 1
First Name

Emergency Contact 1
Last Name

Emergency Contact 1 Relationship

e.g. grandparent, aunt, family friend, etc.

Emergency Contact 1 Phone

Emergency Contact 2
First Name

Emergency Contact
Last Name

Emergency Contact 2 Relationship

e.g. grandparent, aunt, family friend, etc.

Emergency Contact 2 Phone

SCHOOL DISCLAIMER

If we or our emergency contact cannot be reached cannot be reached in the event of a medical emergency, we hereby give permission to the physician or hospital selected by the school or its selected representative, to hospitalize and/or secure proper treatment for our child(ren) named above. We understand that any costs incurred will be our responsibility.

From time to time, limited information about your child(ren) may be disclosed beyond the scope of Emanuel. This may include the release of students' ages, grades, images, artwork, writing or other school related work to the media for publicity, displays, newsletters, etc. If you do not consent to the release of information, you must notify the temple office in writing, prior to the start of the school year.

Subtotal - Tuition and Fees

YARZHEIT INFORMATION

You may verify your yarzheit information in the My Account section of the website, which can be found by clicking on your name at the top right of any page on the website. (You will need to be logged in to do this. If you are not logged in, you will see a Login button at the top right of every page.)

If you do not wish to do this online you may contact the temple office to review and update this information.

TOTAL:

Includes Voluntary Community Support, and/or school registration fees.

PLANNED GIVING
Some members select to leave a donation in their Will. These generous contributions are a beautiful and meaningful way to help sustain our community for the next generation. If you are interested in learning more about this or plan to add Emanuel in your estate planning, please check the appropriative boxes below.

I will include Emanuel in my estate planning.

I would like more information on ways to include Emanuel in my will or estate.

ADMINISTRATION

On the next page you will be presented with payment options.

You can set up a single payment or divide it into monthly payments (up to 10 months beginning in July and ending in April).

Important note:

All credit card payments have a 3% convenience fee per charge
ACH (e-check) payments have no convenience fee
Before you submit payment, check the date the payments begin. If you select multiple payments, you can set it to begin July 1, 2023 - the beginning of the new membership year.

Please click the 'Save and Continue' button below.

Mon, May 29 2023 9 Sivan 5783