Remember Us - Participation Registration Form

Samara Hutman
Executive Director
1112 Montana Avenue, #182
Santa Monica, CA 90403
310-656-2806
E-mail:
info@remember-us.org

Please feel free to contact us for more information.

2777 Yulupa Avenue #273, Santa Rosa, CA 95405, 707-570-2883

Please provide your contact information.

*Name:
*Title:
*Congregation/Institution:
*Affiliation:
Website:
*Mailing Address:
*City:
*State:		*Zip:
*Phone:		*Email:

*Preferred Method of Contact:		Phone Email

*Approximate Number of Bnai Mitzvah Per Year:

*How did you learn about Remember Us?

If the primary contact for Remember Us follow-up and implementation is another member of the clergy or staff at your congregation/school, please provide their information:

Name:
Title:
Phone:		Email:

*required fields