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 ii Morn Eve i 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 Morn Eve 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 Please Select Never Been Married Married (Please Specify Date) Widowed (Please Specify Date) Divorced Date [DD / MM / YYYY] Divorced Date [DD / MM / YYYY] "Get" Administered by SECTION V | Children 1. Name Hebrew Name Gender Male Female School Birth Date [DD / MM / YYYY] / / Birth Time Morning Evening 2. Name Hebrew Name Gender Male Female School Birth Date [DD / MM / YYYY] / / Birth Time Morning Evening 3. Name Hebrew Name Gender Male Female School Birth Date [DD / MM / YYYY] / / Birth Time Morning Evening 4. Name Hebrew Name Gender Male Female School Birth Date [DD / MM / YYYY] / / Birth Time Morning Evening 5. Name Hebrew Name Gender Male Female School Birth Date [DD / MM / YYYY] / / Birth Time Morning Evening 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 $91.66 monthly $1100 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,s000 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: $140 / Seat Non-Members: $220 / 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 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 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 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 This page uses 128 bit SSL encryption to keep your data secure.
