Chabad of Parkland Membership Application 5779 - 2018/19

 

Members who are renewing their membership please click here.

Please fill in as much information as possible. Thank you!

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
         
Check One: Cohen Levi Israel   Check One: Cohen Levi Israel

SECTION III: PERSONAL INFORMATION
Address   Email 1
City/State/Zip   Email 2
Home Phone   Marital Status
Work Phone   Anniversary Date / /
MM / DD / YYYY format

SECTION IV: 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

SECTION V: 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 VI: MEMBERSHIP CONTRIBUTIONS - ANNUAL


 Benefactor: $1800

Family: $700

Senior Couples: $360

Single or Single Parent Family: $360

Senior Single: $250

 

All members receive 2 seats for High Holiday services (Benefactors receive 4)

If you wish to reserve additional seats please add names below at $60 per seat.

Additional seat names (Separate each name with a comma):

Charge options:

 One full payment of:

Please charge:

 Visa M/C AMEX
  Quarterly payments, each Card #:
  Monthly payments of each Exp. Date

Payment Method:

Credit Card
Check
 		Optional Comments:


SECTION VII: CHOICE OF LOCATION

Rosh Hashana Services: (Sept 10-11)

 

Yom Kippur Services:(Sept 18-19) Marriott ONLY

Marriott Hotel Service

Loxahatchee Rd. Service

Main Combined Service

Sephardic Service

  High Holiday Seating Requests:

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 a Rabbi for a confidential arrangement.