Chabad Club Membership 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.
SECTION 1: YOUR INFO
Full Name*
First NameLast Name
Hebrew NameIf known
First NameLast Name
Mother's Hebrew NameIf known
Father's Hebrew NameIf known
Birth Date
MonthDayYear
E-mail*
Jewishness*
From BirthConvertNot Jewish
FamilyIf known
KohenLeviYisroel
Occupation
Cell Number*
Area CodePhone Number
Work Number
Area CodePhone Number
Home Number
Area CodePhone Number
SECTION 2: SPOUSE INFO
If applicable
Full Name
First NameLast Name
Hebrew NameIf known
First NameLast Name
Mother's Hebrew NameIf known
Father's Hebrew NameIf known
Birth Date
MonthDayYear
E-mail
Jewishness
From BirthConvertNot Jewish
Family
KohenLeviYisroel
Occupation
Cell Number
Area CodePhone Number
Work Number
Area CodePhone Number
Home Number
Area CodePhone Number
SECTION 3: PERSONAL INFORMATION

Address*

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

Marital Status
Anniversary Date
MonthDayYear
SECTION 4: CHILDREN
If applicable
Child 1
First NameLast Name
Birth Date 1
MonthDayYear
Child 2
First NameLast Name
Birth Date 2
MonthDayYear
Child 3
First NameLast Name
Birth Date 3
MonthDayYear
Child 4
First NameLast Name
Birth Date 4
MonthDayYear
Are any of the children adopted?
YesNo
If yes, please provide (confidential) information
Have they converted? When? With whom? etc.
SECTION 5: YAHRTZEIT INFORMATION
If applicable
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.
SECTION 6: MEMBERSHIP LEVEL
Any annual "no strings" donation of $1560 or more enters you into the Chabad Club.
Membership OptionsOne share in Chabad's annual budget is $1560. Please choose an amount that is financially comfortable for you.
Founder: $24,000 Annual - $2,000 MonthlyPlatinum: $18,720 Annual - $1,560 MonthlyGold: $12,000 Annual - $1,000 MonthlySilver: $9,240 Annual - $770 MonthlyBronze: $6,480 Annual - $540 MonthlyDouble Chai: $4,320 Annual - $360 MonthlyChai: $2,160 Annual - $180 MonthlyNest: $1,800 Annual - $150 MonthlyPartner: $1,560 Annual - $130 MonthlyAssociate: $770 Annual - $65 Monthly
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%

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Postal / Zip Code

Country

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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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