SECTION I Your Information Last Name First Name Hebrew Name Father's Hebrew Name Mother's Hebrew Name Occupation Birth Date [DD / MM / YYYY] Day Night Jewish by Birth Converted I am a Cohen Levi Israel Cell Phone Work Phone Email SECTION II Spouse's Information Last Name First Name Hebrew Name Father's Hebrew Name Mother's Hebrew Name Occupation Birth Date [DD / MM / YYYY] Day Night Jewish by Birth Converted I am a Cohen Levi Israel Cell Phone Work Phone Email SECTION III Personal Information Address City/State/Zip Home Phone Marital Status: Single Never been Married Married Divorced Widowed Anniversary Date [DD / MM / YYYY] Divorce Date (if applicable) [DD / MM / YYYY] If divorced, do you have a Jewish Get? Yes No Who was Get administered by? Widowed Date (if applicable) [DD / MM / YYYY] SECTION IV Children Child 1 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Child 2 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Child 3 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Child 4 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Child 5 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Child 6 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Child 7 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Child 8 Male Female Name Hebrew Name Birth Date [DD / MM / YYYY] / / Day Night School Are any children adopted? Yes No If yes, give details, including any conversion info: SECTION V Yahrtzeits Name [English / Hebrew / Father's Hebrew / Last] Date of Passing [DD / MM / YYYY] Day Night Relationship Name [English / Hebrew / Father's Hebrew / Last] Date of Passing [DD / MM / YYYY] Day Night Relationship Name [English / Hebrew / Father's Hebrew / Last] Date of Passing [DD / MM / YYYY] Day Night Relationship Name [English / Hebrew / Father's Hebrew / Last] Date of Passing [DD / MM / YYYY] Day Night Relationship Name [English / Hebrew / Father's Hebrew / Last] Date of Passing [DD / MM / YYYY] Day Night Relationship Name [English / Hebrew / Father's Hebrew / Last] Date of Passing [DD / MM / YYYY] Day Night 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. Please select the option of your choice: Partnership Annual Monthly Family Partnership $1,000 $100 Seniors/Single Parent $700 $70 Annual Monthly Section VII Chai Club Opportunities Be a partner in our valuable work and community! Give Chai! Get Chai! The Chai Club is comprised of individuals committed to the financial support of Chabad of Puerto Rico. We rely on the commitment of the people of our community to ensure the financial stability of our organization. A crucial element of support for our work comes from hard-working individuals who commit to a monthly contribution. These monthly donations add up and make a great difference in covering our operational budget. It's a great opportunity to give charity and to give back to Chabad for all we do. Any amount is really significant. As the Talmud says, “each and every penny adds up to a large amount”. Please select the option of your choice: Chai Club Partnership Level Annual Monthly Chai Parternship $1,800 $180 Silver Partnership $2,600 $260 Gold Partnership $3,600 $360 Diamond Partnership $5,000 $500 Platinum Partnership $18,000 $1,800 Annual Monthly Section IX Payment Details I would like to make a High Holiday Seat donation: $100 per adult, please include seats $25 per child, please include seats (not including today’s payment). Please charge my card below on the first day of every month. Total Amount $ Card Type Please Select Visa Mastercard American Express Discover Card Number Expiration Date Month 01 02 03 04 05 06 07 08 09 10 11 12 Year 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Card Security Code Comments/Special Requests ~ NOBODY WILL BE TURNED AWAY DUE TO LACK OF FUNDS ~ * 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 the full amount requested, contact the Rabbi @ [email protected] for a confidential arrangement. This page uses 128 bit SSL encryption to keep your data secure.
