JCA Membership Registration

NEW MEMBER REGISTRATION

MEMBERSHIP REQUESTED

Family

Individual

HAVE YOU PREVIOUSLY BEEN A MEMBER OF THE JCA?

Yes

(1) NAME OF ADULT JOINING THE JCA

First Last

DATE OF BIRTH

HEBREW NAME (if known)

OCCUPATION

WORK PHONE

CELL PHONE

(2) NAME OF ADULT JOINING THE JCA

First Last

DATE OF BIRTH

HEBREW NAME (if known)

OCCUPATION

WORK PHONE

CELL PHONE

HOUSEHOLD HOME PHONE

HOUSEHOLD ADDRESS

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(1) NAME OF CHILD IN YOUR HOUSEHOLD

First Last

DATE OF BIRTH

GRADE

HEBREW NAME (if known)

(2) NAME OF CHILD IN YOUR HOUSEHOLD

First Last

DATE OF BIRTH

GRADE

HEBREW NAME (if known)

(3) NAME OF CHILD IN YOUR HOUSEHOLD

First Last

DATE OF BIRTH

GRADE

HEBREW NAME (if known)

(4) NAME OF CHILD IN YOUR HOUSEHOLD

First Last

DATE OF BIRTH

GRADE

HEBREW NAME (if known)

NAME OF PARENT NOT IN HOUSEHOLD: If a parent of one or more of these children in not living in your household (e.g. divorced or separated), please provide name and contact information below.

First Last

ADDRESS

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PHONE

ANY ADDITIONAL MEMBERSHIP INFORMATION YOU WOULD LIKE US TO KNOW

PLEASE NOTE: Your contact information will be entered into the JCA database and shared with staff and committee chairs only as needed. Unless you request otherwise, it will be included in the JCA Guidebook/Membership Directory that is distributed to the JCA membership annually. The directory may not be used for business or political purposes.