Membership Financial Adjustment Request Form

Member Information

First Name:

Last Name:

Email:

Phone:

Membership Dues Structure

Age categories are based on eldest member in a household
Individual membership includes one adult High Holy Day ticket
Family membership includes two adult High Holy Day tickets
Basic membership does not include High Holy Day tickets

Individual Membership

Blum 36+: $1,360Malkov 36+: $1,360Sanctuary All Ages: $1,675Balcony All Ages: $1,485

Family Membership

Blum Under 31+: $875Blum 31-35: $1,570Blum 36+: $2,375Malkov Under 31: $875Malkov 31-35: $1,570Malkov 36+: $2,375Balcony All Ages: $2,600Sanctuary All Ages: $2,875

Basic Membership

Individual All Ages: $1,035Family All Ages: $1,675

Requested Adjustment

After reviewing the membership dues, please indicate an amount that is both meaningful and comfortable to your budget.

Membership Dues:

To be paid in:

A $175 Security Fee will be added to Membership Dues unless other arrangements are made.

Total to be charged:

Payment Method:

Credit Card Payment Information

First Name on Card

Last Name on Card

Credit Card Number

Expiration Month

MM

Expiration Year

YYYY

Use different billing address

Billing Address

Billing City

Billing State

Billing Zip Code

ACH/eCheck Information

Bank Routing Number

Bank Account Number

Bank Account Type

Bank Name

Account Holder Name

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