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Membership Form 5777

Membership Form 5777

chabad logo.JPG

Chabad of Southwest Broward 5777 2016/2017

Personal Information

Family Name Home Phone

Address City, State, Zip

Your Details
Name Hebrew Name

Father's Hebrew Name Mother's Hebrew Name
Date of Birth
Hebrew Birthday
Work Phone Cell Email

Spouse Information
Name Hebrew Name
Date of Birth
Hebrew Birthday
Work Phone Cell Email

Marital Status

Married, Anniversary

Divorced, Date:

Child(ren) Information

Yahrtzeit (parents or children)

Name (English/Hebrew/Last) Father's Hebrew Name Relationship Date & Time of Death

Platinum Family Membership $1800 Annually
Gold Family Membership $1500 Annually
Silver Family Membership $1200 Annually
Honorary Family Membership $900 Annually

Gold and Silver Family Membership includes seats for your immediate family and a special Gold or Silver Membership plaque on the Membership Board. Honorary Family Membership includes 4 seats and $50 for each additional seat for immediate family. Single Parent Family Membership includes 3 seats and $50 each for additional seats. In addition, all membership entitles you to discounts on Hebrew School and youth club tuitions, discounts on facilities usage and much, much more.

High Holiday Seat Reservations
High Holiday Services this year will be help at the Westin in Fort Lauderdale and at our regular location at 10601 Stirling Road in Cooper City. Please indicate the number of all adults and children attending High Holiday Services on Rosh Hashana: October 3rd - 5 th and Yom Kippur: October 11th – 12th.

We will be attending services at:

The flagship service at the Westin Fort Lauderdale Beach Chabad of Cooper City

Number of Adults: Number of Children (13 & under):


Payment Details: Seats for your entire immediate family are included with Gold and Silver Membership. Honorary membership includes 4 seats. Additional seats are available for $50 per seat for Honorary Members’ immediate family. Seats are $150 at the Marriott and $100 at Chabad of Cooper City for non-members. Save $50 per seat by reserving your seats before September 15, 2014.

Yahrtzeit Plaque $540.00 memorial board.jpg

Yes, I would like to purchase a plaque in memory of a loved one.
Not at this time


Hebrew Name

Father's Hebrew Name Date of Passing am pm


Name Hebrew Name

Father's Hebrew Name Date of Passing am pm

Tree of Life Leaves $180.00

Yes I would like to purchase a leaf in honor of a family member or loved one.
Not at this time

In Honor Of:
In Honor Of:
In Honor Of:

Payment Options

Membership $ + Seats $ + Yahrtzeit Plaque $ + Tree of Life $ =

Total: $

I will send in a check made payable to Chabad of Southwest Broward.

Please charge my Credit Card.
Card Number Exp. Date CCV
Billing Address (if Different)

I hereby certify that all information given above is true and correct and that I, and all members of my immediate family named herein, are Jewish by birth, or by conversion in accordance with Orthodox Jewish Law (Halacha).

Electronic Signature: Date:

Should you require assistance completing this form, please call us at 954-252-1770

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