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)
Applicant Information
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*

Spouse Information
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
Children Information
Please list children living in your household. Family members living in a separate household are to submit a separate form.
Please list all children info:
One child per line: Please include Name / Hebrew Name / Birthdate - mm-dd-yyyy / Gender
Yahrtzeit Information
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.
High Holiday Seating
Seat reservations are for adult members of your household only. Interactive age appropriate youth programs will be held for children under 13 years old.
# of Men
# of Women
# of Children (under 13 years old)
Payment Information

Payment*

Credit Card

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.
Should be Empty:

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Applicant Information