Male Member (or Husband in Family Unit)

(M) Last Name:        First Name:

                                                                          Hebrew Name:

H Birthdate:   

H Father's Secular  Name:   H Father Hebrew Name :  

Date of Death (if applicable):

H Mother's Secular  Name:   H Mother Hebrew Name :

Date of Death (if applicable):

H Bar Mitzvah Date and Parsha:

Willing to Read Torah: Yes  No             Willing to Read Haftorah: Yes  No

Female Member (or Wife in Family Unit)

(F) Last Name:        First Name:

                                                                       Hebrew Name:

W Birthdate:

W Father's Secular  Name:   W Father Hebrew Name :  

Date of Death (if applicable):

W Mother's Secular  Name:   W Mother Hebrew Name :

Date of Death (if applicable):

W Bar Mitzvah Date and Parsha:

Willing to Read Torah: Yes  No             Willing to Read Haftorah: Yes  No

Anniversary Date:

Children: 0 1 2 3 4 5

Child #1:      Hebrew Name:     Birthdate:

Child 1 Bar Mitzvah Date and Parsha:

Child #2:      Hebrew Name:     Birthdate:

Child 1 Bar Mitzvah Date and Parsha:

Child #3:      Hebrew Name:     Birthdate:

Child 3 Bar Mitzvah Date and Parsha:

Child #4:      Hebrew Name:     Birthdate:

Child #4 Bar Mitzvah Date and Parsha:

Child #5:      Hebrew Name:     Birthdate:

Child #5 Bar Mitzvah Date and Parsha:

Additional information on children:

GrandParent Yahrzeits (provide relationship; date of death and Secular and Hebrew name):

Spouse Yahrzeits (provide date of death, Secular and Hebrew name):

Children Yahrzeits: (provide date of death and Secular and Hebrew name):

Other Yahrzeits You Wish to Be Reminded of:

If you have any further additions or changes please contact the Center office or email at office@hollishillsjc.org