Become a MEMBER and enjoy special valuable benefits & exciting new perks! Returning members, click here SECTION I | Your Information Last Name First Name Hebrew Name Father's Hebrew Name Mother's Hebrew Name Occupation Birth Date [DD / MM / YYYY] Day Night Jewish by Birth Conversion I am a Cohen Levi Israel Cell Phone Work Phone Email SECTION II | Spouse's Information Last Name First Name Hebrew Name Father's Hebrew Name Mother's Hebrew Name Occupation Birth Date [DD / MM / YYYY] Day Night Jewish by Birth Conversion Not Jewish I am a Cohen Levi Israel Cell Phone Work Phone Email SECTION III | Personal Information Address City/State/Zip Home Phone Marital Status: Single Never been Married Married Divorced Widowed Anniversary Date [DD / MM / YYYY] Divorce Date (if applicable) [DD / MM / YYYY] If divorced, do you have a Jewish Get? Yes No Who was Get administered by? Widowed Date (if applicable) [DD / MM / YYYY] SECTION IV | Children Child 1 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Child 2 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Child 3 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Child 4 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Child 5 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Child 6 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Child 7 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Child 8 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Are any children adopted? Yes No If yes, give details, including any conversion info: SECTION V | Yahrtzeits Name [English / Hebrew / Father's Hebrew / Last] Date of Passing [DD / MM / YYYY] Day Night Relationship Name [English / Hebrew / Father's Hebrew / Last] Date of Passing [DD / MM / YYYY] Day Night Relationship Name [English / Hebrew / Father's Hebrew / Last] Date of Passing [DD / MM / YYYY] Day Night Relationship Name [English / Hebrew / Father's Hebrew / Last] Date of Passing [DD / MM / YYYY] Day Night Relationship Name [English / Hebrew / Father's Hebrew / Last] Date of Passing [DD / MM / YYYY] Day Night Relationship Name [English / Hebrew / Father's Hebrew / Last] Date of Passing [DD / MM / YYYY] Day Night Relationship Section VI | Membership Opportunities Basic Membership • Complimentary tickets to Annual Membership Melava Malka Gala • Two High Holiday seats • Listing of departed loved ones in Yizkor Booklet • 25% discount on Hebrew School • 20% discount on Bar/Bat Mitzvah fees (after 1st year of membership – must be enrolled in our Hebrew School) • 5% discount on Gan Chamesh Preschool 2017/18 • 10% discount on most events and programs • Menorah & Candles for Chanukah mailed to college age children at school • Life Cycle event services • Meals delivered for new babies and shiva • Belonging to an amazing Jewish community & building lifelong friendships The Annual Dues Scheule: $1,440 Family Membership $120 Monthly Payment $770 Single Membership TREE OF LIFE PARTNERSHIP CLUB – A MONTHLY DEDICATION OPPORTUNITY Tree of Life partnership Club includes Membership Benefits and a leaf dedication plaque on the beautiful Tree of Life Wall Chai - $180 Double Chai - $360 Triple Chai - $540 Chabad Connection - $770 Includes all of the above and 2 seats to Chabad’s Annual Dinner Includes all of the above benefits plus a prominent Aliyah at High Holiday Services, admission with RSVP to any Chabad event gratis: Builder - $1,300 Chai Minyan - $1,800 Hashem's Partner - $2,600 Silver Partner - $3,600 Gold Partner - $5,400 Diamond Partner - $7,200 Jubilee Chai Partner - $9,000 Includes all of the above benefits and a complimentary table at Chabad’s Annual Dinner: Visionary - $10,000 Community Pillar - $13,000 Chai Chazak- $18,000 Section VII | High Holiday Seat Reservations Click Here to reserve your High Holiday Seats - Use Discount Code: MEM for 2 free seats Section VIII | Payment Authorization I would like to make a one time payment for everything pledged above. Please charge my card below. I would like to make recurring monthly payments for membership (not including today's payment). Please charge my card below on the first of every month. I would like to make recurring monthly payments for building fund (not including today’s payment). Please charge my card below on the first day of every month. I would like to make recurring monthly payments for High Holiday Seats (not including today’s payment). Please charge my card below on the first day of every month. Total Amount Pledged - Membership $ Total Amount Pledged - High Holiday Seats $ Total Amount Pledged - Tree of Life $ Comments/Special Requests Amount to be charged TODAY [First recurring payment or one time amount] $ Card Type Please Select Visa Mastercard American Express Discover Card Number Expiration Date Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Card Security Code I hereby certify that all information given above is true and correct. This page uses 128 bit SSL encryption to keep your data secure.
