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 Please Select Single Married Divorced Widowed 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 Select January February March April May June July August September October November December Select 2020 2021 2022 2023 2024 2025 2026 2027 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. This page uses 128 bit SSL encryption to keep your data secure.