*

Has your personal information changed ?

We can only contact you based on the information you provide below !

TEXAS information update page !

The information you provide here will help us maintain contact with you and provide you with current information about our planned activities. Your submission of this form will constitute your consent to the collection and transfer of this information for internal Mosaic use.

First Name
Last Name
Address  
Apt#  
City  
State           
Country    
(5 or 10-digit) Zip Code
Home Phone
Work/Cell Phone
Birth date ,

Gender
Industry

Other:


Occupation

Other:


Your primary E-mail address is your ID and is used to verify your information
(example format: mench23@zipple.com or Rebecca_Rosen@yahoo.com or Catscan@caremail.com)
Primary E-mail :
Secondary E-mail :

Please select the description that best matches your level of Jewish observance,
so we can take it into consideration when planning an activity.
Not selected Reform Reconstructionist Conservative
Conservodox Orthodox Hassidic Lubavitch
I authorize Mosaic to include the following information in the Mosaic Membership Directory distributed to Mosaic members in good standing (select those that apply):
All Name
Address
Phone-H
Phone-W 		E-mail
B-day
Occupation
None

I would like to participate on the following committees. (select those that apply):
Membership
Publicity
Calendar Schedule
Planning Events 		Newsletter / Editing
Internet / Web Development
Social Committee
Other:

Your Interest Below

In which activities do you take a particular interest?
Biking Yes No Not selected
Swimming Yes No Not selected
Picnics / Day Trips Yes No Not selected
Stargazing Yes No Not selected
Oneg Shabbat Dinners Yes No Not selected
Social Parties Yes No Not selected
Environmental Projects Yes No Not selected
Fishing Yes No Not selected
Horseshoes / Washers Yes No Not selected
Rock Climbing Yes No Not selected
Horseback Riding Yes No Not selected
Softball Yes No Not selected
Volleyball Yes No Not selected
Tennis Yes No Not selected
Water Skiing Yes No Not selected
Snow Skiing Yes No Not selected
Snorkeling Yes No Not selected
Scuba Diving Yes No Not selected
Sailing Yes No Not selected
Running / Jogging / Walking Yes No Not selected
Ice Skating Yes No Not selected
Inline Skating Yes No Not selected
Tubing / Rafting Yes No Not selected
Kayaking Yes No Not selected
Canoeing Yes No Not selected
Hiking / Backpacking Yes No Not selected
Frisbee Yes No Not selected
Golfing Yes No Not selected
Camping Yes No Not selected
Other

Can event leaders contact you when they are planning an event in which you expressed interest?

Yes, please contact me using: The E-mail address above   
  Please don't contact me.

Other Comments ?

Please review your entries above.

Revised : 29 Sept 2005