Congregational Plan Application Form 2022-2023

June 1, 2022 to May 31, 2023

11301 W. Broward Boulevard, Plantation, FL 33325 954-472-3600/ Fax 954-472-3622 ramatshalom@ramatshalom.org

Household Information

Family Name: *

Home Phone: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Adult 1 Name: *

Adult 1 Hebrew Name: *

Adult 1 Date of Birth:

Adult 1 Cell Phone: *

Adult 1 Email: *

Adult 1 Occupation:

Adult 1 Business Name:

Adult 1 Business Phone:

Adult 1 Business Address:

Address Line 1

Address Line 2

City

State

Zip Code

Adult 2 Name:

Adult 2 Hebrew Name:

Adult 2 Date of Birth:

Adult 2 Cell Phone:

Adult 2 Email:

Adult 2 Occupation:

Adult 2 Business Name:

Adult 2 Business Phone:

Adult 2 Business Address:

Address Line 1

Address Line 2

City

State

Zip Code

Marital Status

Date Married:

Does Ramat Shalom have permission to share your contact information with the congregation? *

Yes
No

Please include all children to age 26

Child 1 Name:

Child 1 Identified Gender:

Child 1 Hebrew Name:

Child 1 Date of Birth:

Child 1 Date of Bar/Bat:

Child 1 School:

Child 1 Secular School Grade as of 8/2022:

Child 1 Email:

Child 2 Name:

Child 2 Identified Gender:

Child 2 Hebrew Name:

Child 2 Date of Birth:

Child 2 Date of Bar/Bat:

Child 2 School:

Child 2 Secular School Grade as of 8/2022:

Child 2 Email:

Child 3 Name:

Child 3 Identified Gender:

Child 3 Hebrew Name:

Child 3 Date of Birth:

Child 3 Date of Bar/Bat:

Child 3 School:

Child 3 Secular School Grade as of 8/2022:

Child 3 Email:

Child 4 Name:

Child 4 Identified Gender:

Child 4 Hebrew Name:

Child 4 Date of Birth:

Child 4 Date of Bar/Bat:

Child 4 School:

Child 4 Secular School Grade as of 8/2022:

Child 4 Email:

Do You Have Loved Ones Whose Names You Would Like Placed On Our Yahrzeit List?

(Yahrzeit List 1) Name:

(Yahrzeit List 1) Relation to/of:

(Yahrzeit List 1) English Date Of Death:

(Yahrzeit List 1) Time of Death:

Before sundown
After sundown

(Yahrzeit List 2) Name:

(Yahrzeit List 2) Relation to/of:

(Yahrzeit List 2) English Date Of Death:

(Yahrzeit List 2) Time of Death:

Before sundown
After sundown

(Yahrzeit List 3) Name:

(Yahrzeit List 3) Relation to/of:

(Yahrzeit List 3) English Date Of Death:

(Yahrzeit List 3) Time of Death:

Before sundown
After sundown

Are You Or Your Spouse Related To Any Ramat Shalom Members?

Yes
No

Member

Relationship

Please Refer To The Fee Schedule To Complete The Following:

Congregational Fees

Opportunities to Give!

Congregational Fees (Section A on Fee Sheet):

Torah School Assistance Fund:

Registration Fee $100 (waived before 6/15):

Gift of the Heart Scholarship Fund:

Torah School/iServe Fees (Section B on Fee Sheet):

Sam & Laura Hoffman Scholarship Fund:

Torah School Registration Fee $100 (waived before 6/15):

Burning the Mortgage Fund:

Additional Fees

Congregational Fees SUB-TOTAL :

Security: (Required per household)

$200.00

Additional Fees SUB-TOTAL:

Kochavim: (Youth Choir)

$80/child

Opportunities to Give SUB-TOTAL:

TOTAL:

*Separate application for Torah School and youth programs MUST be completed for each child.

Payment Options

Pay in Full
Pay in 4 Installments, $12/payment installment fee (payments due: 6/1, 8/1, 10/1, 12/1)
Pay in 10 Installments, $12/payment installment fee (payments due monthly beginning on 6/1)

NOTE: If you are paying in installments, please contact our office. Whenever possible, we appreciate your payment by check or cash. All credit card transactions will be assessed a 3% convenience fee.

Payment Information

Check #:

Check Amount Enclosed:

Am. Express, Visa, MasterCard, Discover Account #:

Expiration Date:

Name (as it appears on credit card):

Credit Card Billing Address:

Address Line 1

Address Line 2

City

State

Zip Code

The congregational year for Ramat Shalom begins June 1st, 2022. I understand that membership dues are payable annually and are not transferable or refundable. In the event that I am unable to meet any of these payments or require a change in my payment arrangement, it is my obligation and responsibility to notify the Director of Administration to avoid losing my membership-in-good-standing and the attendant rights.

Electronic Signature: *

Date: *

By clicking Submit, I authorize Ramat Shalom to automatically charge the above credit card according to the method of payment specified above. *

Click to accept

Congregational Plan Application Form 2022-2023

June 1, 2022 to May 31, 2023

Household Information

Please include all children to age 26

Do You Have Loved Ones Whose Names You Would Like Placed On Our Yahrzeit List?

Please Refer To The Fee Schedule To Complete The Following:

Congregational Fees

Opportunities to Give!

Additional Fees

Payment Information

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