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First Name Hebrew name
Last Name Birthday
Spouse's Name

Spouse's Hebrew Name

Spouse's Birthday Anniversary
Address  
City Zip
Home Phone Fax
Work Phone Spouse's Work Phone
Email Spouse's Email

Mi Shebeirach/Aliya Infromation:

Are you, your spouse, or either of your parents converts? (please specify):
No Yes

Parents' Hebrew Name  
Father: Mother:
   
Spouse's Parents' Hebrew Name  
Father: Mother:

Childrens Information
Name (English) Hebrew M/F Birthdate Grade
M F
M F
M F
M F
M F

Yahrtzeits
(Date of the passing of loved ones):
Name (English) Hebrew Relationship

Date of Passing

I would like to see the JLC provide the following services/programs:

Date Application Form Submitted:

Comments:

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