Membership

Membership 2024/2025

Please complete our membership form.
PERSONAL INFORMATION
Full Name*
First Name Last Name
Cell Number*

Area Code Phone Number
Home Number

Area Code Phone 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

Month Day Year
Born

DayEvening
Family

CohenLeviYisroelConvert
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
Marital Status
Anniversary Date

Month Day Year
Children (If applicable)
1.Full Name
First Name Last Name
Birth Date

Month Day Year
Born

DayEvening
Please check

MaleFemale
2. Full Name
First Name Last Name
Birth Date

Month Day Year
Born

DayEvening
Please check

MaleFemale
3. Full Name
First Name Last Name
Birth Date

Month Day Year
Born

DayEvening
Please check

MaleFemale
4. Full Name
First Name Last Name
Birth Date

Month Day Year
Born

DayEvening
Please check

MaleFemale
Yahrzeits (parents or children)
1. Full Name
First Name Last Name
Hebrew Name
Relationship
Date of passing

Month Day Year
Time of Day

DayEvening
2. Full Name
First Name Last Name
Hebrew Name
Relationship
Date of passing

Month Day Year
Time of Day

DayEvening
3. 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.
Membership Options*

$26,000 Builders of the Community (Includes Shul Security, plaque in our lobby with your name, 4 High Holiday seats for adults)$18,000 Founder of the Community (Includes Shul Security, plaque in our lobby with your name, 4 High Holiday seats for adults)$10,000 Pillar of the Community (Includes Shul Security, plaque in our lobby with your name, 4 High Holiday seats for adults)$5,000 Gold Membership (Includes Shul Security, plaque in our lobby with your name, 4 High Holiday seats for adults)$3,600 Honorary Membership (Includes Shul Security, plaque in our lobby with your name, 4 High Holiday seats for adults)$2000 Family Membership ( Includes Shul Security, 2 High Holiday seats for adults)$1000 Single Membership (Includes Shul Security, 1 High Holiday seat for adult)$900 Seasonal Associate Friend of Chabad ( Includes Shul Security)
Membership to be paid:*

In Full12 monthly payments
Membership auto renewal*

YesNo
Comments
Security Fund
I would like to contribute towards Shul Security

$540$250$180$1000
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 2024 - Aug 31st 2025
I would like to be a member

$450 Yearly Men's Membership for the Mikvah
Membership auto renewal

YesNo
LOCKER RENTAL
Locker rentals will run from Sept 1st 2024 - Aug 31st 2025
Yearly Rental

$180 Yearly rental of a located in daily shul
Rental auto renewal

YesNo
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

I would like to receive news and updates by email
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PERSONAL INFORMATION

FAMILY SECTION

MEMBERSHIP PLAN

Security Fund

CHAI FOR LIFE

MIKVAH MEI CHAYA MUSHKA & MIRIAM

LOCKER RENTAL

PAYMENT