Request an Immersion during our Queer Jewish Affirmation Celebration!

Please fill out the form below to request an immersion slot during our Queer Jewish Immersion Celebration on June 21. If you are requesting an appointment for more than one person, please select "Add another response" at the bottom of the form; you must use a unique email for each adult.

A note about our Immersion Fees

Mayyim Hayyim is a nonprofit institution which relies on community support to help maintain our building, staff and the educational programs and events we provide the community. It is customary to give tzedakah (a charitable contribution) when visiting a mikveh.

Please give an amount that feels meaningful to you - no one is turned away from Mayyim Hayyim for lack of funds. You will have an opportunity make a payment via links in your confirmation email after your immersion has been scheduled. You will also be able to pay on-site on the 21st with cash or check.

Contact Information of Person Immersing

I am filling this form out on behalf of a child (under 18)

YesNo

First name

Last name

Date of Birth of person immersing

Gender

Pronouns

Parent/Guardian First Name if under 18

Parent/Guardian Last Name

Email of parent/guardian

Email of person immersing

Phone

Address

City

State

Postal Code

Country

Immersion Information

Please request your immersion time at least two (2) business days in advance. Although not always possible, we will do our best to accommodate other requests.

When submitting a request, you can expect:

Your increased flexibility within the posted hours and requesting appointments farther in advance will yield a higher likelihood of confirming your appointment.
An email from our staff to either confirm your requested time or suggest alternative options.

We are offering 30 minute appointment slots during this event. Our first immersion starts at 5pm, and our last immersion starts at 7:30pm.

What time would you like to immerse? Please share three times in order of preference:

First Choice Time

Yes, I am flexible by 30 minutes before or after this time choice.

This is the only time I am available; no need to offer other optionsI have some flexibility and can offer other options

Second Choice Time

Yes, I am flexible by 30 minutes before or after this time choice.

Third Choice Time

Yes, I am flexible by 30 minutes before or after this time choice.

Anything else you would like us to know about your availability?

Reason for Immersion

Other

If you expect to bring any guests with you, please let us know about how many (up to 10) you expect to join:

Are there any access needs that we should be made aware of to ensure greatest ease, safety and comfort?

Is there anything else you'd like us to know to help make this experience as meaningful as possible?

How will you be paying for this immersion?

Please select the reason that most closely describes what prompted your decision to request this immersion

Contact Information