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SECTION I: YOUR INFO   SECTION II: SPOUSE'S INFO
Name   Name

Hebrew Name   Hebrew Name
Father's Hebrew
Name		   Father's Hebrew
Name
Mother's Hebrew
Name		   Mother's Hebrew
Name
Birth Date / /
  Birth Date / /
Jewish by: Birth Converted   Jewish by: Birth Converted
Check One: Cohen Levi Israel   Check One: Cohen Levi Israel
SECTION III: PERSONAL INFORMATION
Address   Email 1
City/State/Zip / /   Phone
SECTION IV:  CHILDREN (OPTIONAL)

Name

  

Birth Date

 / /

Name

  

Birth Date

 / /
SECTION V: YAHRZEIT INFORMATION  (OPTIONAL)

Name
  / /
Date of Passing 		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.
Founder $3,000 Monthly - $36,000 Annually
Diamond Partnership $1,500 Monthly - $18,000 Annually
Platinum Partnership $1,000 Monthly - $12,000 Annually
Gold Partnership $500 Monthly - $6,000 Annually
Silver Partnership $360 Monthly - $4,320 Annually
Bronze Partnership $250 Monthly - $3,000 Annually
Chai Partnership $150 Monthly - $1,800 Annually
Family Partnership $100  Monthly - $1,200 Annually

 
SECTION VII: PAYMENT INFORMATION
  Payment Method:  
Card Number:
Expiration  
CVV Code:
  Optional Comments: I wish to pay the full annual donation
I wish to pay 12 Month Installments
You will be charged at the beginning of each month.
Begin payments on:

Other Payment Method:
       
   

TOTALS:

 
    Partnership Total Amount:

    Total Amount to be charged today:


* 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 for a confidential arrangement.