Membership Form 2022-23 • 5783

Personal Information

Family Name Home Phone

Address City, State, Zip

Your Details
Name Hebrew Name

Father's Hebrew Name Mother's Hebrew Name
Date of Birth Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1970 1971 1972 1973 1974 1975 1976 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Hebrew Birthday
Work Phone Cell Email

Spouse Information
Name Hebrew Name
Date of Birth Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1970 1971 1972 1973 1974 1975 1976 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Hebrew Birthday
Work Phone Cell Email

Marital Status

Married, Anniversary

Divorced, Date:

Child(ren) Information

Yahrtzeit (parents or children)

Membership
 Chabad Family Membership $1200 Annually • $100 Monthly
Bronze Family Membership $1800 Annually • $150 Monthly
Silver Family Membership $3000 Annually • $250 Monthly
Gold Family Membership $3600 Annually • $300 Monthly 
Platinum Family Membership $6000 Annually • $500 Monthly 

*Monthly Chai Club : In addition to Membership, please charge my card a monthly donation of:

$  

High Holidays at Chabad:

No Tickets Necessary  Everyone is welcome • Donations greatly needed & appreciated •Due to limited space: Guarantee a seat: $100
Two free reserved seats with your membership
ChabadSWB.com/donate

High Holidays @ Bahia Mar on Ft. Lauderdale Beach:

No Tickets Necessary Everyone is welcome •  Suggested Donation: $150 • Free with your membership 

KosherHolidayResort.com

Yahrtzeit Plaque $540.00

Yes, I would like to purchase a plaque in memory of a loved one.
Not at this time

Name

Hebrew Name

Father's Hebrew Name Date of Passing am pm

----------------------------------

Name Hebrew Name

Father's Hebrew Name Date of Passing am pm

Tree of Life Leaves $360.00

Yes I would like to purchase a leaf in honor of a family member or loved one.
Not at this time

In Honor Of:
In Honor Of:
In Honor Of:

Payment Options

Membership $ + Seats $ + Yahrtzeit Plaque $ + Tree of Life $ =

Total: $

I will send in a check made payable to Chabad of Southwest Broward.

Please charge my Credit Card in one payment.   Monthly over 12 payments
Card Number Exp. Date CCV
Billing Address (if Different)

I hereby certify that all information given above is true and correct and that I, and all members of my immediate family named herein, are Jewish by birth, or by conversion in accordance with Orthodox Jewish Law (Halacha).

Electronic Signature: Date:

Should you require assistance completing this form, please call us at 954-252-1770