Membership Type
 First time joining (please fill out all section I - IX)  
 Membership Renewal (please fill out name and email, then skip to section VIII)
Last Name
First Name
Email
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
Check here to subscribe to Chabad West Hemsptead's e-mails
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
$70.84 monthly
$850 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
Service Type
 I would like to participate in services in the INDOOR Minyan
 I would like to participate in services in the OUTDOOR Minyan
Please indicate the name of all adults and children attending services on Rosh Hashana and Yom Kippur.
Members: $120 / Seat Non-Members: $200 / 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)
Billing Address
City/State/Zip
  
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