To download these documents, please click here.

SECTION I: YOUR INFO

SECTION II: SPOUSE'S INFO

Name

 

Name
Hebrew Name   Hebrew Name
Father's Hebrew
Name 		  Father's Hebrew
Name
Mother's Hebrew
Name		   Mother's Hebrew
Name
Occupation   Occupation
Birth Date / /
MM / DD / YYYY format 		  Birth Date / /
MM / DD / YYYY format
Jewish by: Birth Converted   Jewish by: Birth Converted
Check One: Cohen Levi Israel   Check One: Cohen Levi Israel

SECTION III: PERSONAL INFORMATION
Address   Email
City/State/Zip   Cell
Home Phone   Marital Status
Work Phone   Anniversary Date / /
MM / DD / YYYY format
Work Fax   If Divorced: If divorced, do you have a
Jewish "Get" ? Yes No
Work Address   Work City/State/Zip

SECTION IV: SPOUSE'S PERSONAL INFORMATION
Cell   Email
Work Address   Work City/State/Zip
Work Phone   Work Fax
If Previously Divorced: Do you have a
Jewish "Get" ? Yes No 		     

SECTION V: CHILDREN

Name

 

Birth Date

 / /
MM / DD / YYYY format

Name

 

Birth Date

 / /
MM / DD / YYYY format

Name

 

Birth Date

 / /
MM / DD / YYYY format

Name

 

Birth Date

 / /
MM / DD / YYYY format

Name

 

Birth Date

 / /
MM / DD / YYYY format

Name

 

Birth Date

 / /
MM / DD / YYYY format
Are any children adopted? Yes No   If yes, give details, including any conversion info:

SECTION VI: 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

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

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 VII: MEMBERSHIP OPPORTUNITIES 5778 (2017-2018)
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.

Please check the option of your choice

 

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

SECTION VIII: CHAI CLUB OPPORTUNITIES 5778 (2017-2018)
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.
We rely on the commitment of the people of our community to ensure the financial stability of our organization. A crucial element of support for our work comes from hard-working individuals who commit to a monthly contribution. These monthly donations add up and make a great difference in covering our operational budget.
It's a great opportunity to give charity and to give back to Chabad for all we do. Any amount is really significant. As the Talmud says, “each and every penny adds up to a large amount”.
To learn more about the Chai Club, please click here.

Please check the option of your choice

 

 
  Additional Monthly Additional Annually
Partner Level $40 $432
Executive Level $80 $864
Innovator Level $120 $1296
     
SECTION IX: 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 @ [email protected] for a confidential arrangement.