Membership

Membership 2022-23/5783 Online Form
SECTION I: MEMBER NAME
Full Name*

First Name Last Name
All my information is the same as last year.
Hebrew Name*
Father's Hebrew Name*
Mother's Hebrew Name*
Occupation*
Birth Date*

Month Day Year
Check One:*

Cohen Levi Israel
Check One:*

Jewish by birth. Converted.
Details:
Yes, I would like to add:

My Spouse Children Yarzteits
SECTION II: SPOUSE'S INFO (Optional)
Full Name

First Name Last Name
Hebrew Name
Father's Hebrew Name
Mother's Hebrew Name
Occupation
Birth Date

Month Day Year
Check One:

Cohen Levi Israel
Check One:

Jewish by birth. Converted.
Details:
SECTION III: PERSONAL INFORMATION (Optional)

Address

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

Home Phone

Area Code Phone Number
Work Phone

Area Code Phone Number
Work Fax

Area Code Phone Number
E-mail 1
E-mail 2
Marital Status
Anniversary Date

Month Day Year
SECTION IV: CHILDREN (Optional)
Names of Children and Birth Dates Ex: Chana Dec. 4, 2001
Are any children adopted?

Yes No
If yes, give details, including any conversion info:
SECTION V: YAHRZEIT INFORMATION (Optional)
Yahrzeit 1
1. Name English / Hebrew / Father's Hebrew / Last
1. Date of Passing

Month Day Year
1. Relationship
Yahrzeit 2
2. Name English / Hebrew / Father's Hebrew / Last
2. Date of Passing

Month Day Year
2. Relationship
Yahrzeit 3
3. Name English / Hebrew / Father's Hebrew / Last
3. Date of Passing

Month Day Year
3. Relationship
Yahrzeit 4
4. Name English / Hebrew / Father's Hebrew / Last
4. Date of Passing

Month Day Year
4. Relationship
SECTION VI: MEMBERSHIP & PARTNERSHIP OPPORTUNITIES
You fuel Jewish Life in Hallandale/Hollywood Beach happens with your generous support. Membership plays an important role providing a warm and welcoming environment for services, community events, and adult education. Thank You for joining.

Members will receive discounts on various community classes and events throughout the year.
Please select*

Standard Membership: $1200 (includes 4 High Holidays Seats) Supporter Membership: $1800 (includes 4 High Holidays Seats) Executive Membership: $3600 (includes 4 High Holidays Seats + High Holiday Honor) Shareholder Membership: $5400 (includes 4 High Holidays Seats + High Holiday Aliya) Snowbird Membership: $720 (6 months minus 1 day) Snowflake Membership: $540 (Less than 3 months) Flexible ($1-$99 monthly) __ (includes 2 High Holiday Seats) - Specify $ below.
Please accept my monthly donation of:

$
Total

$0.00

Payment

Credit Card Check in the mail.

Postal / Zip Code

Country

Comments
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