ABRIDGED FORM FOR CURRENT MEMBERS ONLY  

Signing up as a member for the first time?  Click here for the full form.

 

SECTION I:  ADULT MALE

 

 SECTION II:  ADULT FEMALE

Name, First Last

 

Name, First Last

 

SECTION II: FAMILY UPDATE - since September 2010
CONTACT INFO      
New Address     New Home Phone  
New Email (male)     New Cell (male)
New Email (female)     New Cell (female)  

CHILDREN

 

 

 
Hebrew/English Name   Date of Birth /  / MM / DD / YYYY format
      Time of Day:  (approx)

  YARTZEITS

 

    
English Name
Hebrew Name
   Relation Date of Yartzeit / Time of Day

 

/  / MM / DD / YYYY format

 

/  / MM / DD / YYYY format
 

  

SECTION VI: MEMBERSHIP CONTRIBUTIONS

Membership

Annual  

Monthly 

Patron $5,000   $416
Benefactor $2,500   $209
  Family (Includes 2 High Holiday Seats)
 $1,800    $150
 Young Family (head of household under 35) (Includes 2 High Holiday Seats)
 $1,000    $84

 Senior Family (head of household over 65) (Includes 2 High Holiday Seats)

  $1000    $84
 Single or Single Parent (over 35) (Includes 1 High Holiday Seat)
 $750    $62.50
Newlywed (1st Year of Marriage) (Includes 2 High Holiday Seats)  Free    
 Associate $600    $50
Security Fee:   $100    $10

• Payment in full by cash, check or credit card
• Monthly & Quarterly payments using a credit card on file or check. Your credit card will be charged on the first business day of your selected payment schedule.

       
Please charge my: Visa M/C  AMEX   Exp.
Card #:    
Email      
       

Additional Support 

For those that can help us, we would greatly appreciate your donation of additional funds by adding to your membership dues. Your additional funds will also help Chabad support those in need of scholarships and it will allow us to expand our activities.

$500 Additional Support:    

Other Additional Support: 
I would like the above total amount to be contributed from the above Credit Card per the payment schedule below:
 full payment
bi-annually 		quarterly
monthly
Optional Comments:
     
SECTION VII: REQUESTS FOR FINANCIAL ASSISTANCE
Chabad of Dallas wishes to accept all who want to be members and participate in its programs regardless of financial means. Our financial chair will contact you and a mutually agreed upon fee will be arranged. this will occur in a strictly confidential manner. No person or family will be turned away due to lack of financial means. Please use the following area to state reason for financial assistance request:

please contact me on my: home phone  cell phone      (as shown above)