Membership Form

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 (under the age of 18)
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$2,150 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

180.00 (Suggested amount)
KIDDUSH FUND
The cost to sponsor to basic Pareve Kiddush is $1500.
Yes, I would like to contribute to the Kiddush Fund

180.00 (Suggested amount)
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*

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Credit Card Check or Zelle

Postal / Zip Code

Country

I would like to receive news and updates by email
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MEMBER

SPOUSE (IF APPLICABLE)

PERSONAL INFORMATION

CHILDREN (under the age of 18)

YAHRZEITS (parents or children)

MEMBERSHIP PLAN

SECURITY FUND

KIDDUSH FUND