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Annual Membership

Annual Membership

Jewish Learning Experience @ Lake Success Chabad

SECTION I: YOUR INFO

SECTION II: SPOUSE'S INFO

Name

Name

Hebrew Name Hebrew Name
Father's Hebrew
Name
Father's Hebrew
Name
Mother's Hebrew
Name
Mother's Hebrew
Name
Occupation Occupation
Birth Date / /
MM / DD / YYYY format
Birth Date / /
MM / DD / YYYY format
Jewish by: Birth Converted Jewish by: Birth Converted
Check One: Cohen Levi Israel Check One: Cohen Levi Israel


SECTION III: PERSONAL INFORMATION

Address Email 1
City/State/Zip Email 2
Home Phone Marital Status
Work Phone Anniversary Date / /
MM / DD / YYYY format
Work Fax If Divorced: If divorced, do you have a
Jewish "Get" ? Yes No

SECTION IV: CHILDREN

Name

Birth Date

/ /
MM / DD / YYYY format

Name

Birth Date

/ /
MM / DD / YYYY format

Name

Birth Date

/ /
MM / DD / YYYY format

Name

Birth Date

/ /
MM / DD / YYYY format

Name

Birth Date

/ /
MM / DD / YYYY format

Name

Birth Date

/ /
MM / DD / YYYY format
Are any children adopted? Yes No If yes, give details, including any coversion info:

SECTION V: YAHRZEIT INFORMATION

Name


English / Hebrew / Father's Hebrew / Last

/ /
Date of Passing: MM / DD / YYYY
Relationship

Name


English / Hebrew / Father's Hebrew / Last

/ /
Date of Passing: MM / DD / YYYY
Relationship

Name


English / Hebrew / Father's Hebrew / Last

/ /
Date of Passing: MM / DD / YYYY
Relationship

Name


English / Hebrew / Father's Hebrew / Last

/ /
Date of Passing: MM / DD / YYYY
Relationship

Name


English / Hebrew / Father's Hebrew / Last

/ /
Date of Passing: MM / DD / YYYY
Relationship

Name


English / Hebrew / Father's Hebrew / Last

/ /
Date of Passing: MM / DD / YYYY
Relationship

SECTION VI: MEMBERSHIP CONTRIBUTIONS - ANNUAL

Friend of Chabad family Membership $2,600

Honorary family Membership $1,800

Membership $1400.00

Payment Options:

One full payment of:

Please chage my:

Visa M/C AMEX
Quarterly payments, each Card #:
Monthly payments of each Exp. Date

Payment Method:

Credit Card
Check is in the mail
Please bill me
Optional Comments:

CAPITAL BUILDING CAMPAIGN
I'd like to make an additional donation towards Lake Success Building campaign.
$360 $770 $1800 $3600 Other

* No one is turned away for lack of funds. If you cannot afford the full amount requested, contact the Rabbi for a confidential arrangement.

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