Membership Application 5787 | 2026-2027 If this is your first time confirming your membership at Chabad of Glendale & River Hills, please complete this form, if you are renewing your membership for 5787, please complete our Renewal Form. PERSONAL INFORMATION Your Name* Hebrew Name* CohenLeviYisroelConvert Father's Hebrew Name Mother's Hebrew Name Birth Date & Time Month Day Year at 123456789101112 Hour000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 MinutesAMPM Address* Street Address Street Address Line 2 City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Cell Phone* Area Code Phone Number E-mail* Occupation* Work Phone Area Code Phone Number MARITAL STATUS MarriedSingle (Never Married)WidowedDivorced If married, enter date: Month Day Year SPOUSE DETAILS Spouse's Full Name First Name Last Name Spouse's Hebrew Name CohenLeviYisroelConvert Spouse's Father's Hebrew Name Spouse's Mother's Hebrew Name Spouse's Birth Date & Time Month Day Year at 123456789101112 Hour000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 MinutesAMPM Spouse's Cell Phone Area Code Phone Number Spouse's E-mail Spouse's Occupation Spouse's Work Phone Area Code Phone Number Children Do you have any children (under 18)* No ChildrenOne ChildTwo ChildrenThree ChildrenFour ChildrenFive ChildrenSix ChildrenSeven ChildrenEight Children Child 1 Name (English) Child 1 Hebrew Name Child 1 MaleFemale Child 1 Birth Date & Time Month Day Year at 123456789101112 Hour000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 MinutesAMPM Child 2 Name (English) Child 2 Hebrew Name Child 2 MaleFemale Child 2 Birth Date & Time Month Day Year at 123456789101112 Hour000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 MinutesAMPM Child 3 Name (English) Child 3 Hebrew Name Child 3 MaleFemale Child 3 Birth Date & Time Month Day Year at 123456789101112 Hour000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 MinutesAMPM Child 4 Name (English) Child 4 Hebrew Name Child 4 MaleFemale Child 4 Birth Date & Time Month Day Year at 123456789101112 Hour000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 MinutesAMPM Child 5 Name (English) Child 5 Hebrew Name Child 5 MaleFemale Child 5 Birth Date & Time Month Day Year at 123456789101112 Hour000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 MinutesAMPM Child 6 Name (English) Child 6 Hebrew Name Child 6 MaleFemale Child 6 Birth Date & Time Month Day Year at 123456789101112 Hour000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 MinutesAMPM Child 7 Name (English) Child 7 Hebrew Name Child 7 MaleFemale Child 7 Birth Date & Time Month Day Year at 123456789101112 Hour000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 MinutesAMPM Child 8 Name (English) Child 8 Hebrew Name Child 8 MaleFemale Child 8 Birth Date & Time Month Day Year at 123456789101112 Hour000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 MinutesAMPM Yahrzeits I have yahrzeits I would like remembered No YahrzeitsOne YahrzeitTwo YahrzeitsThree Yahrzeits Name 1 English First Name Last Name Name 1 (Hebrew) Father's Hebrew Name Relationship Date & Time of Passing Month Day Year at 123456789101112 Hour000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 MinutesAMPM Name 2 English First Name Last Name Name 2 (Hebrew) Father's Hebrew Name Relationship Date & Time of Passing Month Day Year at 123456789101112 Hour000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 MinutesAMPM Name 3 English First Name Last Name Name 3 (Hebrew) Father's Hebrew Name Relationship Date & Time of Passing Month Day Year at 123456789101112 Hour000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 MinutesAMPM DUES SCHEDULE Chabad of Glendale & River Hills' doors are always open to every Jew, yet some have asked how they can participate in a more formal manner. After consultation with participants, we are offering self-assessment sliding scale guidelines for suggested dues. These funds will enable us to maintain our diversity and all-inclusive spirit while meeting the increasing costs and assuring the future of our growing congregation. Please bear in mind, we will never turn any individual or family away who do not have the financial means. Your participation and growth is what matters, not how much you pay. As always, High Holiday seats are free to all. Suggested Membership Dues* $30,000 or less = $180$30,001 to $40,000 = $360$40,001 to $60,000 = $500$60,001 to $80,000 = $900$80,001 to $100,000 = $1,500$100,001 to $150,000 = $2,000$150,001 to $200,000 = $3,000> $200,000 = $4,000 Special Support Levels Benefactor = $5,000Investor = $7,500Pillar = $10,000 *All membership fees can be made in one payment or in monthly installments Total Paying Today* $180$360$500$900$1500$2000$3000$4000$5000$7500$10000 Yes, I'd like to make this a monthly recurring payment. Kiddush Sponsorship Yes! I would like to sponsor a kiddush over the coming year. Please click here to be redirected to our Kiddush page to reserve your preferred date. Or visit GlendaleChabad.org/Kiddush5787 when you want to make a reservation. Yahrzeit Memorial Plaques I would like to dedicate a yahrzeit plaque in memory of a loved one. Please click here to order a Yahrzeit Memorial plaque or visit GlendaleChabad.org/plaque Comments Total $0.00 Yes, I'd like to donate the cost of processing this transaction by adding 3% Payment Credit Card eCheck Credit Card We accept Visa, MasterCard, American Express, Discover Credit Card Number Security Code Name on Card1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Expiration Month2026202720282029203020312032203320342035 Expiration Year Bank Name Routing Number Account NumberCheckingSavingsBusiness Account TypeBilling Address Street Address City State / Province Postal / Zip CodePlease SelectUnited StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChilePeople's Republic of ChinaRepublic of ChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonThe GambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern MarianaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamBritish Virgin IslandsUS Virgin IslandsWallis and FutunaWestern SaharaYemenZambiaZimbabweOther Country Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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