New Members 2025/2026 - Form - Adat Shalom

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New Members 2025/2026

Adat Shalom New Member Application
2025/2026

Thank you for your generous support as a new member of Adat Shalom. Your membership enables our ongoing spiritual and educational programs while strengthening our community for generations to come.

Family Address

* Family Home Address

* City

* State

* ZIP

* Home Phone #:

Date of Wedding Anniversary (if applicable)

Please Select Number of Adults on the Family Account

Member #1 Information

* First Name

* Last Name

* E-mail

* Cell Phone #:

Hebrew Name (please include Father's and Mother's name. Please write in transliterated English)

What tribe of Israel do you belong to?

Bar/Bat Mitzvah Date

Parshah

* Date of Birth (MM/DD/YYY):

Profession / Special Skill

Business Phone #:

Member #2 Information

* First Name

* Last Name

* E-mail

* Cell Phone #:

Hebrew Name (please include Father's and Mother's name. Please write in transliterated English)

What tribe of Israel do you belong to?

Bar/Bat Mitzvah Date

Parshah

* Date of Birth (MM/DD/YYY):

Profession / Special Skill

Business Phone #:

Primary Emergency Contact Information

* Emergency Contact First & Last Name

Emergency Contact E-mail

* Emergency Contact Phone #:

* Relationship with Emergency Contact

Children of Family Information

* Information for Children

* English Name of Child One

Hebrew Name of Child One (English transliteration is ok)

* D.O.B. of Child One (MM/DD/YYYY):

If birth mother is not Jewish, was child converted?

* English Name of Child Two

Hebrew Name of Child Two (English transliteration is ok)

* D.O.B. of Child Two (MM/DD/YYYY):

If birth mother is not Jewish, was child converted?

* English Name of Child Three

Hebrew Name of Child Three (English transliteration is ok)

* D.O.B. of Child Three (MM/DD/YYYY):

If birth mother is not Jewish, was child converted?

* English Name of Child Four

Hebrew Name of Child Four (English transliteration is ok)

* D.O.B. of Child Four (MM/DD/YYYY):

If birth mother is not Jewish, was child converted?

Membership Directory

We publish a Membership Directory annually for members. Please note this is for personal use only and not to be shared or used for business purposes.

If you don't want your personal contact information to be listed in the directory, and only want your name listed, please make sure to select the checkbox below. If you don't want to be included in the directory at all, please email the office.

I DO NOT want to be listed in the Adat Shalom Community Directory

I DO NOT want to be listed in the Adat Shalom Community Directory

Yahrzeit Information

New Members: Please provide yahrzeit information for loved ones below.

We send reminders to active members prior to your loved one's yahrzeit date. Names will be read during the morning Shabbat service prior to the yahrzeit.

* Yahrzeit Information

* English Name

Hebrew Name (if known)

* Relationship / To Whom

* Secular Date of Death (MM/DD/YYYY):

* Before or After Sunset on Secular Date

Hebrew Date of Death (if known)

* English Name

Hebrew Name (if known)

* Relationship / To Whom

* Secular Date of Death (MM/DD/YYYY):

* Before or After Sunset on Secular Date

Hebrew Date of Death (if known)

* English Name

Hebrew Name (if known)

* Relationship / To Whom

* Secular Date of Death (MM/DD/YYYY):

* Before or After Sunset on Secular Date

Hebrew Date of Death (if known)

* English Name

Hebrew Name (if known)

* Relationship / To Whom

* Secular Date of Death (MM/DD/YYYY):

* Before or After Sunset on Secular Date

Hebrew Date of Death (if known)

* English Name

Hebrew Name (if known)

* Relationship / To Whom

* Secular Date of Death (MM/DD/YYYY):

* Before or After Sunset on Secular Date

Hebrew Date of Death (if known)

Memorial Yahrzeit Board

Please check the box below if you're interested in purchasing a memorial yahzreit plaque to honor the sacred memory of your loved one, or if you would like to reserve a space on our memorial yahrzeit board. The Main Office will contact you for further information about the plaque. Cost per plaque or reserved space is $700 and if you select the box below, $700 will be added to today's membership dues.

I'm interested in purchasing a yahrzeit plaque or reserving a location today for $700.00

I'm interested in purchasing a yahrzeit plaque or reserving a location today for $700.00

Tree of Life Plaque

Please check the box below if you're interested in purchasing a Tree of Life plaque to celebrate a simcha or commemorate a milestone. Say Mazal Tov, celebrate an anniversary or b'nei mitzvah! The Main Office will contact you for further information about the plaque. Cost per plaque or reserved space is $180 and if you select the box below, $180 will be added to today's membership dues.

I'm interested in purchasing a Tree of Life plaque or reserving a location today for $180.00

I'm interested in purchasing a Tree of Life plaque or reserving a location today for $180.00

Membership Rates

Please review the table below to find your Member Category and decide upon a payment method. Membership may be paid in full or automatic payment plan. If you choose to pay via payment plan, Erin Goldstein will reach out to you to set up your plan frequency details.

Credit card fees: As of July 1, 2023, a 3% credit card processing fee is automatically included in all credit and debit card transactions. There is no fee with payments made by check, bank check, or ACH.

Payment in Full: By check, credit card, debit card or ACH. For credit/debit card charge, please complete information below. Checks should be made payable to Adat Shalom.

Monthly Payment Plan: Automatic payment plans can be set up, with all payments completed by May 31, 2026. Equal billing payments can be set up for 4x, 6x or 10x, with payments made by either credit card, automatic bank check, or ACH. To pay by ACH, you must set up an account on the Adat Shalom website. Please use the Plaid portal in the “My Payment Methods” section of your Adat Shalom account. For assistance to setup an account or setting up ACH, please contact the office.

Membership Rates 2025-2026

Member Category	Membership	Facilities Fee	Security Fee	Total
Individual	$1,815	$445	$600	$2,860
Family	$2,805	$445	$600	$3,850
Senior Individual (over 64 yrs.)	$1,340	$445	$600	$2,385
Senior Couple (over 64 yrs.)	$2,255	$445	$600	$3,300
Associate Family* (must show proof of affiliation with another synagogue)	$735	-	$600	$1,335
Young Professional (under 35 yrs.)	$325	-	$450	$775
Young Family (children under 4 yrs.)	$595	-	$450	$1,045

*High Holiday tickets are not included with Associate Family Membership Dues. Tickets may be purchased separately.

Religious School 2025-2026

We are planning for a robust Religious School Program in the coming year. A calendar of the fall schedule will be sent to Religious School families in the coming weeks.

Grades	Days Per Week	First Child	Siblings
K – 1^st	1x per week – Sunday Morning (9am – 12pm)	$1,000	$900
2^nd – 7^th	1x per week – Sunday Morning (9am – 12pm)	$1,500	$1,400

B’nei Mitzvah Fee – If your child will be reaching the age of bar/bat mitzvah in the next 3 years, please contact the office to schedule a meeting with the Rabbi.

$1,000

For New Members Only:
The first year of Religious School is free (first child only) with Full Membership Dues.

Please calculate your Religious School tuition dues based of number of children and enter below:

Enter Religious School Tuition here:

Financial Aid

Financial aid is available. Please contact Renalee Pflug in the office at 310-475-4985.

Membership Rate Selection & Breakdown

Select your Member Category from the drop down menu below, and the correlating Facilities Fee and Security Fees will automatically populate.

* Please Select Your 2025-2026 Membership Rate Below:

Facilities Fee

$445

Security Fee

$600

Security Fee

450

Contributions/Donations:

Optional Contribution for Lev Shalem High Holiday Machzor(s)

Optional Contribution for Siddur Lev Shalem for Shabbat & Festivals for home use or as donation to main sanctuary

Optional Yahrzeit Donation, enter donation amount below

Optional General Donation, enter donation amount below

Please Select Your Method of Payment

* Payment Options for Membership 2025-2026

Please Indicate Date of First Payment:

* MM/DD/YYY

Credit Card Information

* Credit Card Number:

* Expiration Date (MM/YYYY):

* Security Code

* Cardholder's Name (as it appears on card)

Address (if different than Home Address)

Membership Commitments

I/We promise to abide by the rules and regulations of Adat Shalom. I (we) agree to pay the first year’s dues in full and thereafter such annual dues as may be fixed by the Synagogue Board of Directors, in accordance with the By-Laws of the Congregation. I (we) understand that the fiscal year for payment of all Adat Shalom accounts is July 1-June 30. I (we) understand that our account must be current in order to have a life cycle event and voting privileges at Adat Shalom.

*Note: Adat Shalom By-Laws are available in the office upon request

* Please Select Number of Members Agreeing to "Membership Commitment" via Digital Signature

* Member #1 Digital Signature (Please Include First and Last Name)

* Today's Date

* Member #2 Digital Signature (Please Include First and Last Name)

Today's Date

Paying Dues after you click "Submit"

Erin Goldstein will reach out to you after you've submitted your application to go over payment information and instructions on how to set up your personal website login.

Membership Dues 2025-2026

Sun, September 21 2025 28 Elul 5785

Contact Us

3030 Westwood Boulevard
Los Angeles, CA 90034
(310) 475-4985|info@adatshalomla.org

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Office Hours

Mondays - Thursdays, 9:00 am - 5:00 pm
Fridays, 9:00 am - 2:00 pm

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