The Brisbane Synagogue: Shabbat Service Form

Shabbat Service Form

APPLICATION TO ATTEND A SHABBAT SERVICE

Please note: all items must be completed throughout this form.
Date of service (US date format) *Please enter the date of the service you wish to attend
Time *Please enter the commencement timeHHMMAM/PM
Reason
Any special reason for attendance (e.g. yahrzeit, birthday, anniversary, etc)
Name *
Your full name
Address *
Your residential addressStreet AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone *Your land line and/or mobile telephone number
Email Your email address
Date of Birth *Please enter your date of birth
Emergency Contact *
Contact in case of emergency (Name, relation, mobile phone/email)
Date *Date of submitting this application to the synagogue
What I am agreeing to By sending this form to the synagogue, I am agreeing to each of the statements accompanying the boxes checked below [Please check the box of each statement to which you agree. Leaving a box unchecked may result in your application not being accepted]
I am the applicant, and I have personally completed all items in this application form. [Note: If it is proposed to make an application for a person aged under 13 years, please contact the synagogue office before completing and submitting this application].
I warrant that the information I have provided is true and correct to the best of my knowledge, and that I have not knowingly provided information which is false, misleading or incomplete.
If, between the time of submitting this application to the synagogue and the scheduled time of commencement of the service I wish to attend, my circumstances change in any way that would result in any information I have provided no longer being true, correct and complete, I will immediately notify the rabbi, the President of the synagogue or a staff member at the synagogue office of full details of the changed circumstances.

Verification

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