SECTION I: YOUR INFO
Name
Hebrew Name
Father's Hebrew Name
Mother's Hebrew Name
Occupation
Birth Date
Jewish by: Birth Converted
Check One: Cohen Levi Israel
SECTION II: SPOUSE'S INFO
Name
Hebrew Name
Father's Hebrew Name
Mother's Hebrew Name
Occupation
Birth Date
Jewish by: Birth Converted
Check One: Cohen Levi Israel
SECTION III: PERSONAL INFORMATION
Address
City/State/Zip
Home Phone
Work Phone
Work Fax
Email 1
Email 2
Marital Status
Anniversary Date
If Divorced: Do you have a Jewish "Get" ?
Yes No
SECTION IV: CHILDREN
Name Birth Date
Name Birth Date
Name Birth Date
Name Birth Date
Name Birth Date
Name Birth Date
Are any children adopted? Yes No If yes, give details, including any conversion info:
SECTION V: YAHRZEIT INFORMATION
Name Date of Passing
Relationship
Name Date of Passing
Relationship
Name Date of Passing
Relationship
Name Date of Passing
Relationship
Name Date of Passing
Relationship
Name Date of Passing
Relationship
SECTION VI: PARTNERSHIP OPPORTUNITIES
In our effort to be inclusive for families of all income levels, Partnership Opportunities have been designed within a wide range. However, if you are capable, please consider participating at a higher level. This will allow us to cover our expenses and continue to expand our programs, services and long term goals. All Partnership gifts can be made in one installment or in 12 monthly installments. Please check the option of your choice. Nobody will be turned away due to lack of funds.
Founder Partnership $4,000 Monthly - $48,000 Yearly
Ruby Partnership $1,500 Monthly - $18,000 Yearly
Platinum Partnership $1,000 Monthly - $12,000 Yearly
Gold Partnership $500 Monthly - $6,000 Yearly
Silver Partnership $360 Monthly - $4,320 Yearly
Bronze Partnership $250 Monthly - $3,000 Yearly
Chai Partnership $180 Monthly - $2,160 Yearly
Family Partnership $125 Monthly - $1,500 Yearly
Associate Partnership $54 Monthly - $648 Yearly
SECTION VII: PAYMENT INFORMATION
Payment Method:
Card Number:
Expiration Date
CVV Code:
Optional Comments:
Please note that if you send a check or setup with your bank you will save Chabad 3.5%
I wish to pay the full annual donation
I wish to pay 12 Month Installments
You will be charged at the beginning of each month.
Begin payments on:
Other:
TOTAL
Partnership Total Amount:
Total Amount to be charged today:

* All contributions are tax deductible and can be paid throughout the year. No one is turned away for lack of funds. If you cannot afford the full amount requested, contact the Rabbi for a confidential arrangement.