Printed from ChabadWesthempstead.org

Membership & Partnership Form

Membership & Partnership Form

SECTION I | Your Information
Last Name
First Name
Hebrew Name
Father's Hebrew Name
Mother's Hebrew Name
Occupation
Birth Date [DD/MM/YYYY]iiBirth Time
iii
Jewish by
Birth Converted
I am a
Cohen Levi Israel
Cell Phone
Work Phone
Home Phone
Email
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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]iiBirth Time
iii
Jewish by
Birth Converted
I am a
Cohen Levi Israel
Cell Phone
Work Phone
Home Phone
Email

Check here to subscribe to Chabad West Hemsptead's e-mails
SECTION III | Personal Information
Home Address
City/State/Zip
Family Name
SECTION IV | Marital Status
Date [DD / MM / YYYY]
Divorced Date [DD / MM / YYYY]
"Get" Administered by
SECTION V | Children
1. Name
Hebrew Name
Gender
School
Birth Date [DD / MM / YYYY]
/ /
Birth Time
2. Name
Hebrew Name
Gender
School
Birth Date [DD / MM / YYYY]
/ /
Birth Time
3. Name
Hebrew Name
Gender
School
Birth Date [DD / MM / YYYY]
/ /
Birth Time
4. Name
Hebrew Name
Gender
School
Birth Date [DD / MM / YYYY]
/ /
Birth Time
5. Name
Hebrew Name
Gender
School
Birth Date [DD / MM / YYYY]
/ /
Birth Time
SECTION VI | Yahrzeits
1. Name
[English / Hebrew / Father's Hebrew / Last]
Date of Passing [DD/MM/YYYY]iiiiTime
ii
Relationship
2. Name

[English / Hebrew / Father's Hebrew / Last]
Date of Passing [DD/MM/YYYY]iiiiTime
ii
Relationship
3. Name

[English / Hebrew / Father's Hebrew / Last]
Date of Passing [DD/MM/YYYY]iiiiTime
iii
Relationship
4. Name

[English / Hebrew / Father's Hebrew / Last]
Date of Passing [DD/MM/YYYY]iiiiTime
iii
Relationship
Section VII | Membership & Partnership Opportunities
All fees can be made in one installment or 12 monthly installments. Choose a membership type and then choose if you would like to pay monthly or through a one-time payment.
Family Membership
$45 monthly
$540 annually
Silver Membership $100 monthly $1,200 annually
Chai Membership $180 monthly $2,160 annually
Gold Membership $250 monthly $3,000 annually
Diamond Membership $360 monthly $4,320 annually
Chabad Membership $1,000 monthly $12,000 annually
Section VIII | High Holiday Seat Reservations
High Holiday services will take place at the West Hempstead JCC. Please indicate the name of all adults and children attending services on Rosh Hashana and Yom Kippur.
Members: $50 / Seat Non-Members: $120 / Seat
Total Price for all HH Seats

Section IX | Payment Information
I will send a check to Chabad of West Hempstead for the above form.
Please charge my credit card below. (Seat payments due in prior to the High Holidays)
First Name Last Name

Card Type
Card Number
Expiration Date
Card Code
Total Charge Amount (Membership + HH Seats)
By typing your name in the box, you are assigning your electronic signature to this document:
Husband

Wife
Should you require assistance with this form, please call us at (516) 596-8691

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