If we have your information on file, there is no need resubmit all the data. Instead please give us any updated information as well as your Membership and Chai Club preference.

SECTION I: YOUR INFO

 

Name

 

Spouse Name

Cell:   Spouse Cell:
Email:   Spouse Email:

SECTION II: PERSONAL INFORMATION

Address   Work Address
City/State/Zip   Work City/State/Zip
Home Phone   Work Phone

SECTION III: 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

SECTION IV: MEMBERSHIP OPPORTUNITIES 5776 (2015-2016)
Be a part of the Chabad of Mid-Suffolk family.
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.

Please check the option of your choice

 

 

Family Membership $80 Monthly $960 Annually
Seniors/Single Parent $55 Monthly $660 Annually

SECTION V: CHAI CLUB OPPORTUNITIES 5777 (2016-2017)
Be a partner in our valuable work and community! Give Chai! Get Chai!

The Chai Club is comprised of individuals committed to the financial support of Chabad of Mid-Suffolk.
 
To learn more about the Chai Club, please click here.

Please check the option of your choice

 

 

Chai Membership Additional $36 Monthly $432 Annually
Silver Membership Additional $72 Monthly $864 Annually
Gold Membership Additional $108 Monthly $1296 Annually
     
     
SECTION VI: PAYMENT DETAILS
Please charge my      
Card Number   CVV Code
Exp Date   Total


* 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 @ rabbi@ChabadMidSuffolk.com for a confidential arrangement.