Mi Shebeirach Submission Form
Name of Person to Add to Mi Shebeirach List *
Your answer
Your Name *
Your answer
Your Email *
Your answer
Your Relationship to the Person *
As You'd Like it to be Listed
Your answer
Your Phone Number
Your answer
Is she or he a current member of Temple Sholom?
Please leave blank if you're not sure.
Can We List Them Publicly?
Their name will appear on our printed Mi Shebeirach list and on our website.
Does the Person Know They're Being Listed?
Would You Like to be Contacted by the Mitzvah Core?
Temple Sholom's Mitzvah Core can help with delivering food or meals, giving rides to the hospital, doctor's appointments, physical therapy, etc., or just spending time with someone if they are home bound.
Other Info
For example, hospitalization, contact information, etc.
Your answer
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This form was created inside of Temple Sholom.