Chabad of Brookville Congregants Information Your information: Family Name First Name Hebrew Name Father's Hebrew Name Mother's Hebrew name Birthday 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 Address Phone (Home) Email Cel Marital status: Married Divorced Single Widowed select one --- Spouse: First Name Hebrew name Father's Hebrew name Mother's Hebrew name Birthday 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 Children: 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 Comments ------------------------------------------------------------------------------------------------------- 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 Expiration Name on card Address on card (If different from home) This page uses 128 bit SSL encryption to keep your data secure.