You have all my personal info.  Please accept my membership at the level noted below (section VII-VIII) for another year.

SECTION I:  YOUR INFO   SECTION II:  SPOUSE'S INFO
Name   Name
Hebrew Name   Hebrew Name
Father's Hebrew  
Name		   Father's Hebrew  
Name
Mother's Hebrew 
Name		   Mother's Hebrew 
Name
Occupation   Occupation
Birth Date  /    /       Birth Date  /    /    
Jewish by:    Birth    Converted   Jewish by:   Birth     Converted
Check One:    Cohen   Levi   Israel   Check One:   Cohen   Levi   Israel

 

SECTION III:  PERSONAL INFORMATION
Address   Email
City/State/Zip   Cell
Home Phone   Marital Status
Work Phone   Anniversary Date / /   
Work Fax   If Divorced: Do you have a Jewish "Get" ? 
 Yes  No
Work Address   Work City/State/Zip

 

SECTION IV:  SPOUSE'S PERSONAL INFORMATION
Cell   Email
 Work Address   Work City/State/Zip
 Work Phone   Work Fax
 If Previously  Divorced: Do you have a Jewish "Get" ?   Yes  No  

 

SECTION V: CHILDREN

Name

 

 Birth Date

 / /   

Name

 

 Birth Date

 / /   
Name

 

 Birth Date

 / /   
Name

 

 Birth Date

 / /   
Name

 

 Birth Date

 / /   
Name

 

 Birth Date

 / /   
 Are any children adopted?   Yes   No    If yes, give details, including any conversion info:
  

 

SECTION VI: YAHRZEIT INFORMATION

Name
English / Hebrew / Father's Hebrew / Last

 

 / /
Date of Passing		 Relationship

Name

   
English / Hebrew / Father's Hebrew / Last

 

 / /
Date of Passing		 Relationship

Name

   
English / Hebrew / Father's Hebrew / Last

 

 / /
Date of Passing		 Relationship

Name

   
English / Hebrew / Father's Hebrew / Last

 

 / /
Date of Passing		 Relationship

Name

   
English / Hebrew / Father's Hebrew / Last

 

 / /
Date of Passing		 Relationship

Name

   
English / Hebrew / Father's Hebrew / Last

 

 / /
Date of Passing		 Relationship

 

SECTION VII: LAMPLIGHTER OPPORTUNITIES 
All partnership fees can be made in one payment or in 12 monthly installments. 
All partnerships include High Holiday seats.

Please check the option of your choice
Partner $416.67 Monthly $5,000 Annually  
Shareholder $300 Monthly $3600 Annually  
Chai Donor $150 Monthly $1800 Annually  
Lamplighter $100 Monthly $1200 Annually  
       

 

SECTION VIII: PAYMENT DETAILS 
Name on Card
  Card Type
Card Number   CVV Code
Exp Date       Total


If is Chabad policy that each center is supported by the community it serves. All funding for local Chabad programs is solicited locally. No money is sent to Chabad headquarters in New York and neither are we funded or financially supported by them. Your support allows us to continue the important work that we do. Thank you!
 

* All information submitted on these forms is confidential and will not be shared or sold to a third party. 

* All contributions are tax deductible and can be paid throughout the year. No one is turned away for lack of funds. If you cannot afford the full amount requested, contact the Rabbi @ [email protected] for a confidential arrangement.