Jewish Learning Experience @ Lake Success Chabad

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 1
City/State/Zip   Email 2
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

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
Are any children adopted? Yes No   If yes, give details, including any coversion info:

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

Friend of Chabad family Membership $2,600

Honorary family Membership $1,800

Membership $1,500.00

 

Payment Options:

One full payment of:

 

Please chage my:

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

Payment Method:

Credit Card
Check is in the mail
Please bill me 		  Optional Comments:

CAPITAL BUILDING CAMPAIGN
I'd like to make an additional donation towards Lake Success Building campaign.
$360 $770 $1800 $3600 Other

* No one is turned away for lack of funds. If you cannot afford the full amount requested, contact the Rabbi for a confidential arrangement.