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About Us Membership

Partnership Application Form- 5785 - 2024/2025

You have all my info on file. I have included only the recent changes
Full Name*

First Name Last Name
Please select:

CohenLeviYisroelConvert

Home Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail*
Occupation:

Work Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Work Phone:

Area Code Phone Number
Fax:

Area Code Phone Number
Cell:

Area Code Phone Number
Cell carrier (for texting):
Hebrew name:
Father's Hebrew name:
Mother's Hebrew name:
Date of Birth:

Month Day Year
My Bar/Bat Mitzvah was on:
The portion I read was:
Marital Status:

SingleMarriedDivorcedWidowed
Anniversary Date:

Month Day Year
Spouse Full Name

First Name Last Name
Please select:

CohenLeviYisroelConvert
Occupation:
Work Phone:

Area Code Phone Number
Fax:

Area Code Phone Number

Work Address:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Cell:

Area Code Phone Number
Carrier (for texting):
E-mail
Hebrew Name:
Father's Hebrew Name:
Mother's Hebrew Name:
Date of Birth:

Month Day Year
My Bar/Bat Mitzvah was on:
The portion I read was:
Child 1 Full Name:

First Name Last Name
Hebrew Name:

First Name Last Name
Date of Birth:

Month Day Year
Gender:

MaleFemale
School:
Full Name:

First Name Last Name
Hebrew Name:

First Name Last Name
Date of Birth:

Month Day Year
Gender:

MaleFemale
School:
Child 2 Full Name:

First Name Last Name
Hebrew Name:

First Name Last Name
Date of Birth:

Month Day Year
Gender:

MaleFemale
School:
Yartzeits

Chabad of Mid-Suffolk will help you honor their memory. We will send you a Yartzeit candle and reminder prior to the date.
English / Hebrew Name:
Relationship:
Date/Time:

Month Day Year
at Hour Minutes
English / Hebrew Name:
Relationship:
Date/Time:

Month Day Year
at Hour Minutes
English / Hebrew Name:
Relationship:
Date/Time:

Month Day Year
at Hour Minutes
Please contact me before the above dates about having Kaddish said or to sponsor a Kiddush in their memory
Membership Benefits: High Holiday Seats, Discounts to Events, Listing on Networking page, Rabbi’s Services, Weekly Classes, Holiday Programs, Shabbat Services, Lecture Series, Family Events, Receive a 5% discount on your membership if you refer a family, Weekly Email Newsletter, A box of Matzah for Passover, I Love Shabbat package.
Options:

All Partnership fees can be made payable in one or 12 monthly installments (Monthly: credit card only). Monthly charges run August-July.
Please Select:

New MemberRenewal
Seniors/Single Membership:

$72 Monthly$864 Annually
Family Membership:

$100 Monthly$1200 Annually
Join the Chai Club! Chai=Life!
Your additional donation brings tremendous blessing to the entire Jewish community and your family!
Partner Level:

Additional $50 MonthlyAdditional $600 Annually
Executive Level:

Additional $100 MonthlyAdditional $1200 Annually
Innovator Level:

Additional $150 MonthlyAdditional $1800 Annually
Amount of people coming for the High Holidays

$136/seat
I would like to give an additional donation of:

$
All contributions are tax-deductible to the fullest extent allowed by law.
No one is denied synagogue membership due to financial reasons. If needed, please discuss this with the Rabbi.
Notes:
Total

$0.00

Yes, I'd like to donate the cost of processing this transaction by adding 3%

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Credit Card Check

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Country

Signature:*
Date:*

Month Day Year
It is Chabad policy that each center is supported by the community it serves. All funding for local Chabad programs is solic-ited locally. No money is sent to Chabad headquarters in New York and neither are we funded or financially supported by them. Your support allows us to continue the important work that we do. Thank you!

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