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Membership

Please complete our membership form. 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 other than your name.
MEMBER
Full Name*
First NameLast Name
Hebrew Name
Father's Hebrew Name
Mother's Hebrew Name
Birth Date
MonthDayYear
Born
DayEvening
E-mail
Family
CohenLeviYisroelConvert
Cell Number
Area CodePhone Number
Home Number
Area CodePhone Number
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
PERSONAL INFORMATION

Address

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

Marital Status
Anniversary Date
MonthDayYear
CHILDREN
Full Name
First NameLast Name
Birth Date
MonthDayYear
Born
DayEvening
Please check
MaleFemale
Full Name
First NameLast Name
Birth Date
MonthDayYear
Born
DayEvening
Please check
MaleFemale
Full Name
First NameLast Name
Birth Date
MonthDayYear
Born
DayEvening
Please check
MaleFemale
Full Name
First NameLast Name
Birth Date
MonthDayYear
Born
DayEvening
Please check
MaleFemale
YAHRZEITS (parents or children)
Full Name
First NameLast Name
Hebrew Name
Relationship
Date of passing
MonthDayYear
Time of Day
DayEvening
Full Name
First NameLast Name
Hebrew Name
Relationship
Date of passing
MonthDayYear
Time of Day
DayEvening
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*
$10,000 Pillar of the Community$5,000 Gold Membership$3,600 Honorary Membership$1,800 Family Membership$900 Single Membership$720 Seasonal Associate Friend of Chabad
Membership to be paid:*
In Full12 monthly payments
Comments
HIGH HOLIDAY SEAT RESERVATIONS - RESERVED SEATING IS CLOSED. YOU MAY COME AS THERE WILL BE SEATS AVAILABLE.
HIGH HOLIDAY KIDS CLUB
Join the children's program during the High Holiday morning services from 10:30am-2:00pm.
*Games*Sports*Lunch*Snacks*Prizes
Registration required to join - $10 per child
I am registering children for the Kids Program*Children are not registered unless information is entered below
YesNo
1st Child Name
1st Child age
2nd Child Name
2nd Child Age
3rd Child Name
3rd Child age
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
Yes, I would like to be a member
$280 Yearly Membership for the Mikvah
LOCKER RENTAL
Yearly Rental
$180 Yearly rental of a located in daily shul
Total
$0.00
PAYMENT
Your credit card will not be charged until the office has received and processed your membership form.

Payment*

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

I would like to receive news and updates by email
Should be Empty:

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MEMBER

SPOUSE (IF APPLICABLE)

PERSONAL INFORMATION

CHILDREN

YAHRZEITS (parents or children)

MEMBERSHIP PLAN

HIGH HOLIDAY SEAT RESERVATIONS - RESERVED SEATING IS CLOSED. YOU MAY COME AS THERE WILL BE SEATS AVAILABLE.

HIGH HOLIDAY KIDS CLUB

CHAI FOR LIFE

MIKVAH MEI CHAYA MUSHKA & MIRIAM

LOCKER RENTAL

PAYMENT