Let's keep in touch!
Want to keep in the loop on the latest happenings at Chabad Jewish Center of NWBC? Subscribe to our mailing list below. We'll send you information that is fresh, relevant, and important to you and our local community.
Printed from chabadplace.org

Congregant Info

Congregant Info

 Email

We want to be there for you.  Please keep us up to date with what's happening in your family as well as the goings-on of your friends and community.  Please help us by completing a information form to supply us with important dates such as birthday's, yahrtzeit's and other pertinent info.  Forms are available at the office or just fill the form below. 

Though we encourage everyone to support Chabad via optional annual membership dues, this is by no means a pre-requisite for participation. Everyone is always welcome regardless of their contribution level.  We want this to be your family's second home! 

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
 Occupation    Occupation
 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   If Divorced: If divorced, do you have a
Jewish "Get" ?  Yes  No

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: OPTIONAL MEMBERSHIP CONTRIBUTIONS - ANNUAL
Family: $1,500 ~ Single Parent Family: $750 ~ Single: $600*

Payment Options:

One full payment of:

 

 Please chage my:

 Visa   M/C   AMEX
  Quarterly payments, each    Card #:
  Monthly payments of each    Exp. Date

Payment Method:

 Credit Card
 Check is in the mail
 Please bill me
 
  Optional Comments:

All contributions are tax deductible and can be paid throughout the year. No one is turned away for lack of funds. If you cannot afford to contribute at all, your are welcome just the same. 

         

 Email