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Chai Club Membership

What is the Chai Club?
Chai Club Membership is not compulsory. All are welcome to attend any of Chabad's programs.
Your Information:
Full Name:*
First NameLast Name
Hebrew Name:*
Occupation:*
Company's Name:*
Work Phone Number:*
Area CodePhone Number
Birth Date:*
MonthDayYear
E-mail:*
Is biological father Jewish?*
YesNo
Is biological mother Jewish?*
YesNo
Any Conversions in family?*
YesNo
If yes, please provide details:
Spouse Information:
Spouse Name:
Hebrew Name:
Occupation:
Company's Name:
Work Phone Number:
Area CodePhone Number
Birth Date:
MonthDayYear
E-mail:
Is biological father Jewish?
YesNo
Is biological mother Jewish?
YesNo
Any Conversions in family?
YesNo
If yes, please provide details:
Personal Information:

Address:*

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

Home Phone Number:*
Area CodePhone Number
Marital Status:
Anniversary Date:
MonthDayYear
Children:
* Please include Hebrew Name in parentheses
Name:
Birth Date:
MonthDayYear
Name:
Birth Date:
MonthDayYear
Name:
Birth Date:
MonthDayYear
Name:
Birth Date:
MonthDayYear
Name:
Birth Date:
MonthDayYear
Name:
Birth Date:
MonthDayYear
Yohrtzeits:
Name (English):
Hebrew Name:
Relationship:
Date of Passing:
MonthDayYear
Name (English):
Hebrew Name:
Relationship:
Date of Passing:
MonthDayYear
Name (English):
Hebrew Name:
Relationship:
Date of Passing:
MonthDayYear
Chai Club Opportunities:
Founder: $5000 [$416 per month]Partner: $3600 [$300 per month]CHAI CLUB - “Sustaining amount” $1800 [$150 per month]Hebrew School Family Membership: $1000 [$84 per month]CHAI CLUB (SEASONAL): $700 [$58 per month]
Payment Options:
I am paying the full amount at this time.I am making 12 equal installments
Total to charge today:
$
Capital Campaign:
I'd like to make an additional donation to help pay down the mortgage.
Membership is renewed each year unless otherwise stated.
$54$72$180$360
Payment Information:
Total:
$0.00

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

Should be Empty:

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