Striar Jewish Community Center

Striar Jewish Community Center Membership Application

Directions:

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When completed, mail or fax this form with your credit card information or check to:

Membership
Striar JCC
445 Central Street
Stoughton MA 02072

Fax: (781) 341-2340

You are:

Mr.

Mrs.

Ms.

Dr.

Clergy

Married

Single

Name:

Your Birthdate:

Home Address:

Apt:

City/Town:

State:

Zip:

Home Telephone:

E-mail:

Your Spouse:

Mr.

Mrs.

Dr.

Clergy

Name:

Birthdate:

In case of energency notify:

Phone:

Relationship:

Your Children:

Name:

Birthdate:

Male

Female

Name:

Birthdate:

Male

Female

Name:

Birthdate:

Male

Female

Name:

Birthdate:

Male

Female

Name:

Birthdate:

Male

Female

Your Health Insurance Provider:

Your Health Insurance ID Number:

Your Occupation:

Business Name:

Phone:

Bus. Address:

City/Town:

State:

Zip:

Your Spouse's Occupation:

Business Name:

Phone:

Bus. Address:

City/Town:

State:

Zip:

Voluntary Information:

Jewish

Non-Jewish

Intermarried

Synagogue/Church:

Location:


MEMBERSHIP CATEGORY: Click here for membership categories and fees
Family	Senior	Individual
Family	Individual Social	Adult
Single Parent:	Couple Social	Teen, College
Couple:

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Payment Options: (Please check only one option.)
	Payment in full by Oct. 1 - Cash, check, MasterCard or Visa
	Cash or check MasterCard or Visa

	4 monthly installments dated the 1st of the month
	MasterCard or Visa Post-dated checks

	Automatic Payment via Electronic Funds Transfer (EFT)
		Please obtain an EFT agreement from the Membership Office.

Credit Card Information: (We accept only Visa and MasterCard)

Exact Name on Card:

Credit Card Number:

Expiration Date:

PLEASE NOTE: We will not charge you credit card until we confirm your registration by phone.

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