New Membership Form and Seat Selection

Membership Options*

Family Membership $1200 (Includes all individuals in a single household)Young Membership $900 (Families under 35)Individual Membership $600 (For one person)

Name*

PrefixFirst NameLast Name

Hebrew Name*

Birth Date*

MonthDayYear

Born*

JewishAdoptedConverted

E-mail*

Home Phone Number*

Area CodePhone Number

Cell Phone*

Area CodePhone Number

Work Phone*

Area CodePhone Number

Address*

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

Name (Spouse)

PrefixFirst NameLast Name

Hebrew Name (Spouse)

Birth Date (Spouse)

MonthDayYear

Born (Spouse)

JewishAdoptedConverted

E-mail (Spouse)

Birth Date (spouse)

MonthDayYear

Cell Phone (Spouse)

Area CodePhone Number

Work Phone (Spouse)

Area CodePhone Number

Please list all children info:

One child per line: Please include Name / Hebrew Name / Birthdate - mm-dd-yyyy / Gender

Yahrtzeits

One Yahrtzeit per line. Please include name, Hebrew name, relationship and date/time of passing.

Please note: Uptown Chabad’s open door policy to every Jew remains in full effect. If you feel that your financial situation does not allow for you to pay the standard fees, please contact the office.

# of Men

# of Women

# of Children (under 13 years old)

Payment*

Credit Card

Credit Card Type
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Total Annual Membership

$0.00

Payment Plan*

Pay in fullQuarterly (4 Payments)Monthly (10 Payments)

Comments

Acknowledgement*

I/we acknowledge that membership is subject to the Rabbi's approval.

Applicant Information

Spouse Information

Children Information

Yahrtzeit Information

High Holiday Seating

Payment Information