Membership

Young Israel Chabad of Pembroke Pines
ADULT MALE
Full Name
First Name Last Name
Hebrew Name
Birth Date

Month Day Year
E-mail
Occupation
Jewishness

From BirthConvertNot Jewish
Family

KohenLeviYisroel
Cell Number

Area Code Phone Number
Work Number

Area Code Phone Number
Home Number

Area Code Phone Number
Father's Hebrew Name
Mother's Hebrew Name
Bar Mitzva Parsha
ADULT FEMALE
Full Name
First Name Last Name
Hebrew Name
Birth Date

Month Day Year
E-mail
Occupation
Jewishness

From BirthConvertNot Jewish
Family

KohenLeviYisroel
Cell Number

Area Code Phone Number
Work Number

Area Code Phone Number
Home Number

Area Code Phone Number
Father's Hebrew Name
Mother's Hebrew Name
Yartzeits of Husband
Name
Hebrew Name
Bat/Ben Father's Name
Relationship
Hebrew Yartzeit Date
English Yartzeit Date

Month Day Year
Name
Hebrew Name
Bat/Ben Father's Name
Relationship
Hebrew Yartzeit Date
English Yartzeit Date

Month Day Year
Yartzeits of Wife
Name
Hebrew Name
Bat/Ben Father's Name
Relationship
Hebrew Yartzeit Date
English Yartzeit Date

Month Day Year
Name
Hebrew Name
Bat/Ben Father's Name
Relationship
Hebrew Yartzeit Date
English Yartzeit Date

Month Day Year
PERSONAL INFORMATION

Address

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

Marital Status
Anniversary Date

Month Day Year

Out of Town Address

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

Out of Town Phone Number
CHILDREN
Full Name
First Name Last Name
Birth Date

Month Day Year
Full Name
First Name Last Name
Birth Date

Month Day Year
Full Name
First Name Last Name
Birth Date

Month Day Year
Full Name
First Name Last Name
Birth Date

Month Day Year
Full Name
First Name Last Name
Birth Date

Month Day Year
Full Name
First Name Last Name
Birth Date

Month Day Year
Membership Plan
Please choose your membership option.
Membership dues are tax-deductible.

SINGLE

$350 - Basic Membership
● Name on Members Poster
● $5 off all Shul Dinners

$750 - Upgraded Membership
● Name on Members Poster
● $10 off all Shul Dinners
● 1 High Holiday Seat

$1,800 - Donor
● Name on Members Poster
● 2 FREE Shul Dinners
● 1 High Holiday Seat
● 1 Kiddush in your honor

COUPLE

$700 - Basic Membership
● Name on Members Poster
● $5 off all Shul Dinners

$1,500 - Upgraded Membership
● Name on Members Poster
● $10 off all Shul Dinners
● 2 High Holiday Seats

$3,600 - Donor
● Name on Members Poster
● 4 FREE Shul Dinners

● 1 High Holiday Seat
● 1 Kiddush in your honor
Membership Options*

$350 Basic Membership (Single Member)$700 Basic Membership (Family)$750 Upgraded Membership (Single Member)$1,000 Upgrade Membership (Family)$1,800 Donor (Single Member)$3,600 Donor (Family)
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Young Israel Chabad of Pembroke Pines

ADULT MALE

ADULT FEMALE

Yartzeits of Husband

Yartzeits of Wife

PERSONAL INFORMATION

CHILDREN

Membership Plan