Membership Application

* Denotes required field

 Family Membership          $1200  Chai Club                        $3600
 Single Membership           $1000  Chai Gold Club                $5400
 Newly Married Couple      $1050  Founders Club              $10,000
 Silver Member                 $1800  Founders Chai              $18,000

MEMBER INFORMATION
 Name*

 Hebrew Name

 Phone Number

 
Date of Birth

 Hebrew Birthday

 Email*

Anniversary 

SPOUSE INFORMATION
Name*

 Hebrew Name

 Phone Number

 Date of Birth

 Hebrew Birthday

 Email*

CHILDREN
 Name*

 Hebrew Name

 Birthday

Name*

 Hebrew Name

 Birthday
Name*

Hebrew Name

Birthday

Name*

Hebrew Name

Birthday

YAHRZEITS
 Name*

Date

Relationship

Name*

Date

Relationship
Name*

Date

Relationship

Name*

Date

Relationship

 

INFORMATION
Address*

City

State

Zip Code

Phone Number

 Email*


 

PAYMENT

 

Please choose one of the following:
Credit Card Check Cash

Membership Due :

Extra Donation :   

 
Total : 

Card Type

Card Number*
Expiration Date*
Zip Code*

Please Mail Checks or Cash to:
10165 Cleary Blvd
Plantation, FL 33324

For more information feel free to email us at events@ChabadPlantation.com or call us at 954-370-2289