Chabad of Brookville Congregants Information


Your information:

Family Name

First Name Hebrew Name

Father's Hebrew Name Mother's Hebrew name


Are you a - Cohen  Levi   Yisroel   I'm not sure 

 Is your biological mother Jewish ? 

Jewish by Birth Converted

If converted, please provide more information


Phone (Home) Email Cel

Marital status:


First Name Hebrew name

Father's Hebrew name Mother's Hebrew name


 Are you a - Cohen   Levi  Yisroel  Don't know 

Email cel

 Is your biological mother Jewish ? 

Jewish by: Birth Conversion

If converted please provide more information


Name DOB

Name DOB

Name DOB

Name DOB

Name DOB


Any children adopted? Yes No

Are there any conversions in the family?

If yes, please explain

Any Yahrtzeits you are observing? Please list dates and for whom



Your payment will go to help support the social & educational  programs at the Chabad of Brookville:

(All payments are tax deductible)

Please accept my payment of "Chai" $1,800 


Please accept my double Chai   $3,600      - Double Chai

Please accept my support with  $5,000     - Community Supporter

Please accept my support with $10,000   -Community partner

Please accept my support with $1,8000  - Community Pillar

Please contact me to discuss support through a legacy gift  


No one is turned down due to financial hardship. If you would like to discuss  this, please feel to contact  Rabbi Heber at 516-626-0600. 

Other amount

Pay by electronic check:

Routing number Account number

Pay by credit card:

Card number


Name on card

Address on card (If different from home)