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Membership Form

Names of Adults*
Age Group*
- Under 30
- 31-40
- 41-50
- 51-60
- 61+
Address*
Street Address City State ZIP Code
Home Phone*
Work Phone*
Email #1*
Email #2*
Number of Children
Names, Ages, Gender, and School
Please include information for each child.
Do you prefer:*
(You may select more than one)
- To be placed with adults close to your age?
- To be placed with adults with similar interests?
- To be placed with families with children of similar age?
I/we would like to be in a Havurah with (check all that apply):*
- Singles
- Adults
- Couples
- Families
- Seniors
- Intergenerational
I/We would liket o be in a group with the following NSS Beth El members:
Which activities would ylu like emphasized in a Havurah?*
Please check all that apply.
- Social
- Social action
- Arts/cultural
- Holliday celebration
- Religious
- Education
- Other
If other:
The following section contains optional questions, however, the more information provided and the better we can match you up to meet your needs and interests.
What are your expectations of a Havurah?
Anything else you think would help us place you in a Havurah which meets your needs and interests?
I/We can be described as:*
Check all that apply.
- Native Chicagolander
- Long-time in Chicagoland
- Recent to Chicagoland
- Shomer Shabbat
- Kosher
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