Membership Form & High Holiday Seats 5785

IF YOU ARE RENEWING YOUR MEMBERSHIP, PLEASE ONLY COMPLETE THE REQUIRED INFORMATION.

OTHER AREAS SHOULD BE COMPLETED IF THERE ARE ANY CHANGES FROM LAST YEAR'S FORM.
MEMBER
*

Current MemberNew Member
Full Name*

First Name Last Name
Hebrew Name
Father's Hebrew Name
Mother's Hebrew Name
Birth Date

Month Day Year
Born

DayEvening
Hebrew Birthdate
E-mail*
Family

CohenLeviYisroelConvert
Married

YesNever been marriedWidowedDivorced
Cell Number*

Area Code Phone Number
Home Number

Area Code Phone Number
SPOUSE (IF APPLICABLE)
Full Name

First Name Last Name
Hebrew Name
Father's Hebrew Name
Mother's Hebrew Name
Family

CohenLeviYisroelConvert
Cell Number

Area Code Phone Number
Home Number

Area Code Phone Number
Birth Date

Month Day Year
Born

DayEvening
E-mail
PERSONAL INFORMATION

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Marital Status
Anniversary Date

Month Day Year
CHILDREN
Full Name

First Name Last Name
Birth Date

Month Day Year
Born

DayEvening
Please check

MaleFemale
Full Name

First Name Last Name
Birth Date

Month Day Year
Born

DayEvening
Please check

MaleFemale
Full Name

First Name Last Name
Birth Date

Month Day Year
Born

DayEvening
Please check

MaleFemale
Full Name

First Name Last Name
Birth Date

Month Day Year
Born

DayEvening
Please check

MaleFemale
YAHRZEITS (parents or children)
Full Name

First Name Last Name
Hebrew Name
Relationship
Date of passing

Month Day Year
Time of Day

DayEvening
Full Name

First Name Last Name
Hebrew Name
Relationship
Date of passing

Month Day Year
Time of Day

DayEvening
Full Name

First Name Last Name
Hebrew Name
Relationship
Date of passing

Month Day Year
Time of Day

DayEvening
MEMBERSHIP PLAN

Please choose your membership option. All membership fees can be made in one installment or in 10 monthly installments.
Membership Options*

$36,000 Golden Chai$26,000 Builders$ 18,000 Founders$10,000 Pillar of the Community$5,000 Gold Membership$3,600 Silver Membership$2,600 Honorary Membership$2,000 Family Membership$900 Single Membership$1,000 Seasonal Friend of Chabad
Membership to be paid:*

In Full10 monthly payments
Comments or other payment arrangement you would like
SECURITY FUND
I would like to contribute towards Shul Security

180.00360.00540.00
CHAI FOR LIFE
A contribution of "chai" ($18 or multiples of "chai" per month is a great way to ensure continuous Tzedakah and help our fiscal responsibilities. The contribution you make will be charged to your card monthly.
I am not currently giving each month and would like to contribute monthly:

$18$36$54$108
Please change my current monthly contribution to:
KIDDUSH FUND
The cost to sponsor to basic Pareve Kiddush is $1200.
Yes, I would like to contribute to the Kiddush Fund

180.00360.00540.00850.00
YIZKOR - BOOK OF REMEMBRANCE
We are quickly approaching the High Holidays, a time when Yizkor, memorial prayers, are recited. Each year we reprint our Book of Remembrance, which includes the names of your departed loved ones. If you would like to eternalize their memory, please list the name(s) at a cost of $10 each (unless included in your membership). This information must be in the office by September 26th.
Departed Full Name
Departed Full Name
Departed Full Name
Departed Full Name
Number to be added to Book of Remembrance at $10 each
HIGH HOLIDAY SEAT RESERVATIONS
Members will be scheduled first.
Reserved seats for the High Holidays MUST be reserved in advance.

Please indicate the number of adults and children attending High Holiday Service on:
Rosh Hashana: October 2 - 4 and/or Yom Kippur October 11 - 12

Separate Children's service at 10am during all High Holiday Services.

Seats are valid for entire High Holidays. Please indicate which holiday7 you are attending for our seating arrangement purposes.
Seats are $75 each for men and women (members rate) and $36 for children under 13
You will only be charged for seats that are not included with your membership.
FOR MEMBERS OWNING PEWS yearly membership MUST be maintained in order to reserve pew seats. Please indicate which service(s) you will be attending.

Pew seats are for those who have purchased name plaques.
# of men's pews being used
# of women's pews being used
FOR THOSE WHO DO NOT OWN PEWS WITH PLAQUES, but your membership includes seats, please indicate which service(s) you will be attending.
# of men's seats included in membership being used
# of women's seats included in membership being used
MEMBERS NEEDING ADDITIONAL SEATS:
(excluding those included with your membership)

$75 Men/Women $36 Children under 13
# of men's seats needed
# of women's seats needed
# of boy's seats needed
# of girl's seats needed
Please indicate services you will be attending using the Men's/Boy's Seats* You may check as many boxes as needed

Rosh Hashana October 2 - 4Yom Kippur October 11 - 12Not Applicable
Please indicate services you will be attending using the Women's/Girl's Seats* You may check as many boxes as needed

Rosh Hashana October 2-4Yom Kippur October 11 -12Not applicable
We cannot fully guarantee your seating requests; however, we will try to accommodate the best we can. Thank you.
Comments
Please register below for children's group.
Please indicate names and ages of children for children's groups
Total

$0.00
Your credit card will not be charged until your membership form is processed by the office.
If you are paying by check, your membership will be processed when the check is received.

Payment*

Credit Card Check or Zelle

Postal / Zip Code

Country

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MEMBER

SPOUSE (IF APPLICABLE)

PERSONAL INFORMATION

CHILDREN

YAHRZEITS (parents or children)

MEMBERSHIP PLAN

SECURITY FUND

CHAI FOR LIFE

KIDDUSH FUND

YIZKOR - BOOK OF REMEMBRANCE

HIGH HOLIDAY SEAT RESERVATIONS