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: