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
 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
 Work Phone   Anniversary Date  /   /  
MM / DD / YYYY format
 Work Fax      

 

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: PARTNERSHIP OPPORTUNITIES
In our effort to be inclusive for families of all income levels, Partnership Opportunities have been designed within a wide range. However, if you are capable, please consider participating at a higher level. This will allow us to cover our expenses and continue to expand our programs, services and long term goals. All Partnership gifts can be made in one installment or in 12 monthly installments. Please check the option of your choice. Nobody will be turned away due to lack of funds.
Founder $2,000 Monthly - $24,000 Yearly
Platinum Partnership $1,000 Monthly - $12,000 Yearly
Gold Partnership $500 Monthly - $6,000 Yearly
Double Chai Partnership $360 Monthly - $4,320 Yearly
Silver Partnership $300 Monthly - $3,600 Yearly
Bronze Partnership $250 Monthly - $3,000 Yearly
Chai Partnership $150 Monthly - $1,800 Yearly
Family Partnership $100  Monthly - $1,200 Yearly
Associate Partnership $75  Monthly - $900 Yearly
Other  

 

SECTION VII: PAYMENT INFORMATION

Payment Method:

   Credit Card 
  Check is in the mail   
 		 Optional Comments: 
  Please charge my:   

 I wish to pay the full annual donation 
 I wish to pay 12 Month Installments 
You will be charged at the beggining of each month. 
Begin payments on:  
Other: 
  Card Number:
  Exp. Date       CVV Code:  
 
   

TOTALS: 

 
    Partnership Total Amount:

    Total Amount to be charged today:


* All contributions are tax deductible and can be paid throughout the year. No one is turned away for lack of funds.