"Chabad Club" Member Form

Thank you for choosing to become a partner in the work Chabad does to help people.

Below is the form to join the Chabad Club Membership. Please fill it out as best as you can. At the end of the form you can choose which level of commitment you'd like to make. You can also choose to pay your pledge as a one-time donation, or split it monthly over the course of the year.

Full Name*

First Name Last Name

Hebrew Name If known

First Name Last Name

Mother's Hebrew Name If known

Father's Hebrew Name If known

Birth Date

Month Day Year

E-mail*

Jewishness*

From Birth Convert Not Jewish

Family If known

Kohen Levi Yisroel

Occupation

Cell Number*

Area Code Phone Number

Work Number

Area Code Phone Number

Home Number

Area Code Phone Number

Full Name

First Name Last Name

Hebrew Name If known

First Name Last Name

Mother's Hebrew Name If known

Father's Hebrew Name If known

Birth Date

Month Day Year

E-mail

Jewishness

From Birth Convert Not Jewish

Family

Kohen Levi Yisroel

Occupation

Cell Number

Area Code Phone Number

Work Number

Area Code Phone Number

Home Number

Area Code Phone Number

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Marital Status

Anniversary Date

Month Day Year

Child 1

First Name Last Name

Birth Date 1

Month Day Year

Child 2

First Name Last Name

Birth Date 2

Month Day Year

Child 3

First Name Last Name

Birth Date 3

Month Day Year

Child 4

First Name Last Name

Birth Date 4

Month Day Year

Are any of the children adopted?

Yes No

If yes, please provide (confidential) information

Have they converted? When? With whom? etc.

Please click here to list all the dates of your family member's Yahrtzeits (dates of passing) As a Chabad Club member, these names will be added to the Yizkor book each year, free of charge.

Membership Options One share in Chabad's annual budget is $1560. Please choose an amount that is financially comfortable for you.

I'd like to

Pay this donation all at once. Pay this donation monthly over the course of one year.

Paying by check or credit card? Please write how much you will be paying or mailing today

$0

Total

$0.00

Yes, I'd like to donate the cost of processing this transaction by adding 3%

Payment

Credit Card Check

Postal / Zip Code

Country

Comments, Questions or Suggestions

I would like to receive news and updates by email

Chabad Club Membership Form

SECTION 1: YOUR INFO

SECTION 2: SPOUSE INFO

SECTION 3: PERSONAL INFORMATION

SECTION 4: CHILDREN

SECTION 5: YAHRTZEIT INFORMATION

SECTION 6: MEMBERSHIP LEVEL

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