Membership

Membership 2022/2023
Please complete our membership form.
PERSONAL INFORMATION
Full Name*
First NameLast Name
Cell Number*
Area CodePhone Number
Home Number
Area CodePhone Number
E-mail*

Address*

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

FAMILY SECTION
If you are a current member and there are no changes from last year, there is no need to fill out the family information section
Family Section*
I am a current member with no changes from last yearI am current member and would like to update my informationI am a new member
Hebrew Name
Father's Hebrew Name
Mother's Hebrew Name
Birth Date
MonthDayYear
Born
DayEvening
Family
CohenLeviYisroelConvert
Spouse (If applicable)
Full Name
First NameLast Name
Hebrew Name
Father's Hebrew Name
Mother's Hebrew Name
Family
CohenLeviYisroelConvert
Cell Number
Area CodePhone Number
Home Number
Area CodePhone Number
Birth Date
MonthDayYear
Born
DayEvening
E-mail
Marital Status
Anniversary Date
MonthDayYear
Children (If applicable)
1.Full Name
First NameLast Name
Birth Date
MonthDayYear
Born
DayEvening
Please check
MaleFemale
2. Full Name
First NameLast Name
Birth Date
MonthDayYear
Born
DayEvening
Please check
MaleFemale
3. Full Name
First NameLast Name
Birth Date
MonthDayYear
Born
DayEvening
Please check
MaleFemale
4. Full Name
First NameLast Name
Birth Date
MonthDayYear
Born
DayEvening
Please check
MaleFemale
Yahrzeits (parents or children)
1. Full Name
First NameLast Name
Hebrew Name
Relationship
Date of passing
MonthDayYear
Time of Day
DayEvening
2. Full Name
First NameLast Name
Hebrew Name
Relationship
Date of passing
MonthDayYear
Time of Day
DayEvening
3. Full Name
First NameLast Name
Hebrew Name
Relationship
Date of passing
MonthDayYear
Time of Day
DayEvening
MEMBERSHIP PLAN
Please choose your membership option.
Membership Options*
$18,000 Founder of the Community (Includes plaque in our lobby with your name, 4 High Holiday seats for adults)$10,000 Pillar of the Community (Includes plaque in our lobby with your name, 4 High Holiday seats for adults)$5,000 Gold Membership (Includes plaque in our lobby with your name, 4 High Holiday seats for adults)$3,600 Honorary Membership (Includes plaque in our lobby with your name, 4 High Holiday seats for adults)$1,800 Family Membership (2 High Holiday seats for adults)$900 Single Membership (Includes 1 High Holiday seat for adult)$720 Seasonal Associate Friend of Chabad
Membership to be paid:*
In Full12 monthly payments
Membership auto renewal*
YesNo
Comments
Annual Fees
Annual Fees
$1000 Building Fund (Maintenance & Mortgage Debt$250 Security fee ( Armed Security Personal On Campus)$180 City-Wide Eruv
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.
Monthly contribution
$18 Chai for Life$36 Double Chai$54 Triple Chai
MIKVAH MEI CHAYA MUSHKA & MIRIAM
Membership will run from Sept 1st 2021 - Aug 31st 2022
I would like to be a member
$360 Yearly Men's Membership for the Mikvah
Membership auto renewal
YesNo
LOCKER RENTAL
Locker rentals will run from Sept 1st 2021 - Aug 31st 2022
Yearly Rental
$180 Yearly rental of a located in daily shul
Rental auto renewal
YesNo
HIGH HOLIDAYS SEATS
Please reserve the following HH seats
Please Select*
Using seats on Rosh HashanaUsing seats for Yom KippurUsing seats for both Rosh Hashana and Yom KippurNo seats required for HH
Men HH Seats included in membership
Women HH Seats included in membership
Additional seats required for $175 each
Comments
PAYMENT
Your credit card will not be charged until the office has received and processed your membership form.
Total
$0.00

Payment*

Credit Card Check

Postal / Zip Code

Country

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PERSONAL INFORMATION

FAMILY SECTION

MEMBERSHIP PLAN

Annual Fees

CHAI FOR LIFE

MIKVAH MEI CHAYA MUSHKA & MIRIAM

LOCKER RENTAL

HIGH HOLIDAYS SEATS

PAYMENT