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2024 Partnership Forms for New Members

PERSONAL INFORMATION – HIS
Full Name
First Name Last Name

Address

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

Home Number

Area Code Phone Number
Cell Number

Area Code Phone Number
Occupation
Work Number

Area Code Phone Number

Work Address

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

E-mail
Hebrew Name
Ben (Father’s Hebrew Name)
Ben (Mother’s Hebrew Name)
Birth Date

Month Day Year
Is mother Jewish by birth?

YesNo
KohenLeviYisroelConvertDon't Know
Marital Status

SingleMarriedDivorcedWidowed
PERSONAL INFORMATION – HERS
Full Name
First Name Last Name

Address

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

Home Number

Area Code Phone Number
Cell Number

Area Code Phone Number
Occupation
Work Number

Area Code Phone Number

Work Address

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

E-mail
Hebrew Name
Bat (Father’s Hebrew Name)
Bat (Mother’s Hebrew Name)
Birth Date

Month Day Year
Is mother Jewish by birth?

YesNo
KohenLeviYisroelConvertDon't Know
Marital Status

SingleMarriedDivorcedWidowed
CHILDREN
Child 1 Full Name:
First Name Last Name
Child 1 Hebrew Name:
Child 1 Birth Date:

Month Day Year
Child 1 Gender:

MaleFemale
Child 2 Full Name:
First Name Last Name
Child 2 Hebrew Name:
Child 2 Birth Date:

Month Day Year
Child 2 Gender:

MaleFemale
Child 3 Full Name:
First Name Last Name
Child 3 Hebrew Name:
Child 3 Birth Date:

Month Day Year
Child 3 Gender:

MaleFemale
YARTZEIT INFORMATION
Please complete the form below with your loved one’s Yartzeit information. We will contact you before the Yartzeit to remind you of the date.
Yahrzeit 1: Name of Departed
Yahrzeit 1: Relationship
Yahrzeit 1: Hebrew Name
Yahrzeit 1: Ben (Father’s Hebrew Name)
Yahrzeit 1: Date of Passing

Month Day Year
Yahrzeit 1: Time of Passing

Before NightfallAfter Nightfall
Yahrzeit 2: Name of Departed
Yahrzeit 2: Relationship
Yahrzeit 2: Hebrew Name
Yahrzeit 2: Ben (Father’s Hebrew Name)
Yahrzeit 2: Date of Passing

Month Day Year
Yahrzeit 2: Time of Passing

Before NightfallAfter Nightfall
Yahrzeit 3: Name of Departed
Yahrzeit 3: Relationship
Yahrzeit 3: Hebrew Name
Yahrzeit 3: Ben (Father’s Hebrew Name)
Yahrzeit 3: Date of Passing

Month Day Year
Yahrzeit 3: Time of Passing

Before NightfallAfter Nightfall
In Jewish tradition, a special way to honor our loved ones memory is to inscribe a plaque with their names on a Yahrzeit board. The plaques will be illuminated on the anniversary of your loved one’s passing commemorating their Yartzeit each year, Yiskor, and also on the High Holidays.

The cost of the plaque is $770. Please submit the form by August 30th.

To have your loved one's name added to our beautiful board, please click here
MEMBERSHIP/PARTNERSHIP OPPORTUNITIES
MEMBERSHIP BENEFITS:

-High Holiday Services Reserved Seats. Within a few days of submitting your forms, we will send you via email, a code and instructions on how to access the reservation system.

-Discounted Hebrew School Tuition.

-Discounted Bar and Bat Mitzvah Fees.

-Discounted Rate for Using the Chabad of Cobb Facility.
Membership Options*

*Chai Platinum $500 Monthly*Chai Platinum $5000 Payment in Full*Chai Gold $300 Monthly*Chai Gold $3000 Payment in Full*Family $217 Monthly*Family $2300 Payment in Full*Seniors(70+)/Single Parent $145 Monthly*Seniors(70+)/Single Parent* $1480 Payment in FullAssociate Family $130 Monthly; Seats for High Holiday Services NOT included.Associate Family $1300 Payment in Full; Seats for High Holiday Services NOT Included.Associate Seniors/Single $107 Monthly; Seats for High Holidays NOT included.Associate Seniors/Single $980 Payment in Full; Seats for High Holidays NOT included.
* Includes High Holiday Seats for Immediate Family Members Only
Security Fee of $160 will be charged upon submission of this form.*

I Agree
-All forms must be received by our office no later than August 28, 2024.

-A discount for payment in full is reflected in the payment options above.

-If you select Pay In Full, payment will be processed on submission.

-If you select monthly payments your credit card will be charged the 1st or 15th of each month starting September 1, 2024.

*Please note your card will be charged the $160 Security fee upon submission of this form.
Total

$0.00
For monthly payments please charge my card on the:*

1st of each month15th of each month

Payment*

Credit Card

We accept Visa, MasterCard, American Express, Discover
Credit Card Number	Security Code
Name on Card
Expiration Month	Expiration Year

Billing Address

Street Address

City

State / Province

Postal / Zip Code

Country

Should be Empty:

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PERSONAL INFORMATION – HIS

PERSONAL INFORMATION – HERS

CHILDREN

YARTZEIT INFORMATION

MEMBERSHIP/PARTNERSHIP OPPORTUNITIES