Partnership-Membership Form

Name Your Own Price Membership

Feel Free to Pay What you think we are worth or what you can afford!
Here Are Some Suggestions:
* Any Membership Gift includes two High Holiday Seats
Pick One*
$54 per month/ $648 per yr. - Bronze member -Thank you for your support!$72 per month/ $864 per yr. - Silver Member - Get a Special Donor Appreciation$100 per month / $1200 per yr - Gold Member - The Above Plus a box of Shmurah Matza$136 per month / $1632 per yr. - Platinum Member - All of the Above Plus a Mezuza$180 per month / $2160 per yr. - 10X Chai! -All of the Above Plus one basic KiddushBe a Pillar of YIChabad for just $18x18 = $324 a month ($3,888 yr.)! This includes a plaque on the Memorial Board or two plaques on the Tree of Life
Please Choose From The Following Payment Plans*
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PERSONAL INFORMATION
If there is no new information since the last time you filled out the form, just enter your name and email
Full Name*
First NameLast Name
Hebrew Name
Jewishness
From BirthConvertNot Jewish
Family
KohenLeviYisroel
Occupation
Cell Number
Area CodePhone Number
Work Number
Area CodePhone Number
Home Number
Area CodePhone Number
Birth Date
MonthDayYear
Before or After Sunset
For Hebrew Date Calculation
Marital Status
Anniversary Date
MonthDayYear
E-mail*
Spouse (If Applicable)
Full Name
First NameLast Name
Hebrew Name
Jewishness
From BirthConvertNot Jewish
Family
KohenLeviYisroel
Occupation
Cell Number
Area CodePhone Number
Work Number
Area CodePhone Number
Home Number
Area CodePhone Number
Birth Date
MonthDayYear
Before or After Sunset
E-mail
YAHRTZEITS
Father
MonthDayYear
Before or After Sunset
Mother
MonthDayYear
Before or After Sunset
Father of Spouse
MonthDayYear
Before or After Sunset
Mother of Spouse
MonthDayYear
Before or After Sunset
CHILDREN (If Applicable)
Full Name
First NameLast Name
Birth Date
MonthDayYear
Before or After Sunset
Full Name
First NameLast Name
Birth Date
MonthDayYear
Before or After Sunset
Full Name
First NameLast Name
Birth Date
MonthDayYear
Before or After Sunset
Full Name
First NameLast Name
Birth Date
MonthDayYear
Before or After Sunset
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PERSONAL INFORMATION

Spouse (If Applicable)

YAHRTZEITS

CHILDREN (If Applicable)