Yesodot Family Membership Form (Fax or Mail)Membership in Yesodot is open to Jewish families living in the Greater Boston, Massachusetts area, with a young or adult child with a disability. We welcome those who would like to connect to the Jewish community and encourage the participation of interfaith families, couples and significant others as members and in all of our activities. Some of Yesodot's programs and events are open to the public. There is a $36 annual membership fee.
Yesodot Program, JVS Fax: (617) 542-3992 We will be communicating most often by e-mail |
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| Name: (required) |
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| Street Address: (required) |
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| City: (required) |
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| State: (required) |
MA | ||
| Zip Code: (required) |
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| Phone: (required) |
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| Fax: | |||
| E-mail: (required) |
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| Name of Spouse: | |||
| Name of Child 1: | Date of Birth: | ||
| Name of Child 2: | Date of Birth: | ||
| Name of Child 3: | Date of Birth: | ||
| Name of Child 4: | Date of birth: | ||
| Name of Child 5: | Date of birth: | ||
| Name of Child With Disability: | |||
Does your family receive any supports or services from the Massachusetts Department of Mental Health? ______ Yes _______No: |
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| Nature of the disability: | |||
| Where is the child in school? | |||
| Does your family receive any supports or services from the Department of Mental Retardation or are you on a Waiting List? | |||
| If yes, please describe: |
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| What are your family's family support
needs? |
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| Would you like to volunteer for Yesodot? |
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| Yesodot does not provide medical or therapeutic advice or services and any information you provide to us will NOT be deemed to be a medical record and will NOT be protected under the provisions of HIPAA (the Health Insurance Portability and Accountability Act of 1996). |
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