Aish Chaim Membership

Aish Chaim Membership Form
Name

First Name Last Name
I am a *

Returning Member. My information is the same as last year. Returning Member. I would like to update the following information. New Member.
How many adults (18 and over) plan to attend High Holiday Services?
Number of adult seats
Adult #1

First Name Last Name
Chosen Location (More than one option may be chosen as long as they do not overlap.)

Traditional Minyan Service at the Jaron's Home 8:30AM to 1:00PM Highlighted High Holiday Service at the Willner Home 10:15AM to 11AM High Holiday Speaker at the Willner Home 11:15AM to 12:15PM High Holiday Speaker at the Willner Home 12:30PM to 1:15PM Alternative Class at the Lipstein's 10:15AM to 11:00AM
Adult #2

First Name Last Name
Chosen Location (More than one option may be chosen as long as they do not overlap.)

Traditional Minyan Service at the Jaron's Home 8:30AM to 1:00PM Highlighted High Holiday Service at the Willner Home 10:15AM to 11AM High Holiday Speaker at the Willner Home 11:15AM to 12PM High Holiday Speaker at the Willner Home 12:15PM to 1PM Alternative Class at the Lipstein's 10:15AM to 11:00AM
Adult #3

First Name Last Name
Chosen Location (More than one option may be chosen as long as they do not overlap.)

Traditional Minyan Service at the Jaron's Home 8:30AM to 1:00PM Highlighted High Holiday Service at the Willner Home 10:15AM to 11AM High Holiday Speaker at the Willner Home 11:15AM to 12PM High Holiday Speaker at the Willner Home 12:15PM to 1PM Alternative Class at the Lipstein's 10:15AM to 11:00AM
Adult #4

First Name Last Name
Chosen Location (More than one option may be chosen as long as they do not overlap.)

Traditional Minyan Service at the Jaron's Home 8:30AM to 1:00PM Highlighted High Holiday Service at the Willner Home 10:15AM to 11AM High Holiday Speaker at the Willner Home 11:15AM to 12PM High Holiday Speaker at the Willner Home 12:15PM to 1PM Alternative Class at the Lipstein's 10:15AM to 11:00AM
Adult #5

First Name Last Name
Chosen Location (More than one option may be chosen as long as they do not overlap.)

Traditional Minyan Service at the Jaron's Home 8:30AM to 1:00PM Highlighted High Holiday Service at the Willner Home 10:15AM to 11AM High Holiday Speaker at the Willner Home 11:15AM to 12PM High Holiday Speaker at the Willner Home 12:15PM to 1PM Alternative Class at the Lipstein's 10:15AM to 11:00AM
Adult #6

First Name Last Name
Chosen Location

Traditional Minyan Service at the Jaron's Home 8:30AM to 1:00PM Highlighted High Holiday Service at the Willner Home 10:15AM to 11AM High Holiday Speaker at the Willner Home 11:15AM to 12PM High Holiday Speaker at the Willner Home 12:15PM to 1PM Alternative Class at the Lipstein's 10:15AM to 11:00AM
Where do you predominately see yourself spending the most time?

Traditional davening service at the Jaron's Alternative program and classes at the Willner's/Lipstein's
Do you have children who will attend any part of our services and/or programs?

Yes No
We will be having a younger kids program from 10:00AM to 11:00AM on Shabbos, September 19th at the Goldman's. If planning to attend, please indicate the number of children.
If you have children ages 12 and above please write how many teens do you foresee attending our TEEN PROGRAM at the Lipstein Home from 11:15AM to 1PM?
If you have children between ages 9-11, how many children do you foresee attending our TWEEN PROGRAM at the Willner home from 11:15AM to 1PM?
CHILDREN 17 AND UNDER ARE ENCOURAGED TO ATTEND THE HIGHLIGHTED HIGH HOLIDAY SERVICE AND THEN MOVE TO THEIR DESIGNATED TEEN/TWEEN PROGRAM. How many teens/tweens intend to attend the Highlighted High Holiday Service at the Willner's Home from 10:15AM to 11AM?
Name (ADULT MALE - IF APPLICABLE)

First Name Last Name Suffix
I am a
Hebrew Name
Mother's Hebrew Name
Father's Hebrew Name
Date of Birth

Month Day Year
Date
Occupation
Business Phone

Area Code Phone Number
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name (ADULT FEMALE - IF APPLICABLE)

First Name Last Name Suffix
I am Jewish by birth.

Yes No
Hebrew Name
Mother's Hebrew Name
Father's Hebrew Name
Date of Birth

Month Day Year
Date
Occupation
Business Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Home Phone

Area Code Phone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
CHILD 1
English/Hebrew Name
Age/Date of Birth
English/Hebrew Name
Time of Day When Born (approx. if not sure)
English/Hebrew Name
School/Grade
English/Hebrew Name
CHILD 2
English/Hebrew Name
Age/Date of Birth
English/Hebrew Name
Time of Day When Born (approx. if not sure)
English/Hebrew Name
School/Grade
English/Hebrew Name
CHILD 3
English/Hebrew Name
Age/Date of Birth
English/Hebrew Name
Time of Day When Born (approx. if not sure)
English/Hebrew Name
School/Grade
English/Hebrew Name
CHILD 4
English/Hebrew Name
Age/Date of Birth
English/Hebrew Name
Time of Day When Born (approx. if not sure)
English/Hebrew Name
School/Grade
English/Hebrew Name
CHILD 5
English/Hebrew Name
Age/Date of Birth
English/Hebrew Name
Time of Day When Born (approx. if not sure)
English/Hebrew Name
School/Grade
English/Hebrew Name
ADDITIONAL CHILDREN (not listed above)
If any of your children are attending college, please list their college address, phone and email:
YAHRTZEIT 1
Hebrew Name & Father's Hebrew Name (e.g. Baruch ben Avraham)
English Name
Relation
Date of Yahrtzeit
YAHRTZEIT 2
Hebrew Name & Father's Hebrew Name (e.g. Baruch ben Avraham)
Time of Day (AM/PM)
English Name
Relation
Date of Yahrtzeit
Time of Day (AM/PM)
YAHRTZEIT 3
Hebrew Name & Father's Hebrew Name (e.g. Baruch ben Avraham)
English Name
Relation
Date of Yahrtzeit
Time of Day (AM/PM)
YAHRTZEIT 4
Hebrew Name & Father's Hebrew Name (e.g. Baruch ben Avraham)
English Name
Relation
Date of Yahrtzeit
Time of Day (AM/PM)
SECURITY FEE

To keep our Community safe we will have armed security at all locations at all times. Please consider donating to this fund below.
Would you like to contribute to Aish Chaim's Security Fee? *
Sign-up and payments can be made at www.aishchaim.com/membership/
MEMBERSHIP PAYMENT

Associate memberships are intended for those with full memberships elsewhere.
Name 1

First Name Last Name
Name 2 (if applicable)

First Name Last Name
Phone Number

Area Code Phone Number
Email
example@example.com
PAYMENT BY CHECK
If paying by check, please indicate which of the following memberships you would like to purchase. We will contact you regarding payment arrangements.

PAYMENT BY CREDIT/DEBIT CARD (If paying by check, please indicate above. There is no need to fill this section out if paying by check.)

FAMILY MEMBERSHIP PLUS SECURITY ( $ 1,080.00 for each year )

Full payment now.

SINGLE FAMILY MEMBERSHIP PLUS SECURITY ( $ 900.00 for each year )

Full payment now.

ASSOCIATE MEMBERSHIP PLUS SECURITY ( $ 860.00 for each year )

Full payment now.

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FAMILY HEAD OF HOUSEHOLD OVER 35 (Annual) ( $ 720.00 for each year )

Full payment now.

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FAMILY HEAD OF HOUSEHOLD OVER 35 (Semi-Annual) ( $ 360.00 for each six months )

Accounts charged twice a year.

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FAMILY HEAD OF HOUSEHOLD OVER 35 (Quarterly) ( $ 180.00 for each three months )

Accounts charged four times a year.

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FAMILY HEAD OF HOUSEHOLD OVER 35 (Monthly) ( $ 60.00 for each month )

Accounts charged once a month.

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YOUNG FAMILY, SINGLE, OR SINGLE PARENT (Annual) ( $ 540.00 for each year )

Full payment now.

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YOUNG FAMILY, SINGLE, OR SINGLE PARENT (Semi-Annual) ( $ 270.00 for each six months )

Accounts charged twice a year.

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YOUNG FAMILY, SINGLE, OR SINGLE PARENT (Quarterly) ( $ 135.00 for each three months )

Accounts charged quarterly.

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YOUNG FAMILY, SINGLE, OR SINGLE PARENT (Monthly) ( $ 45.00 for each month )

Accounts charged once a month.

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ASSOCIATE MEMBERSHIP (Annual) ( $ 500.00 for each year )

Full payment now.

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ASSOCIATE MEMBERSHIP (Semi-Annual) ( $ 250.00 for each six months )

Accounts charged twice a year.

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ASSOCIATE MEMBERSHIP (Quarterly) ( $ 125.00 for each three months )

Accounts charged four times a year.

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ASSOCIATE MEMBERSHIP (Monthly) ( $ 40.00 for each month )

Accounts charged once a month.

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ASSOCIATE SINGLE/YOUNG FAMILY MEMBERSHIP ( $ 360.00 for each year )

Full payment now.

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ASSOCIATE SINGLE/YOUNG FAMILY MEMBERSHIP ( $ 180.00 for each six months )

Accounts charged twice a year.

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ASSOCIATE SINGLE/YOUNG FAMILY MEMBERSHIP ( $ 90.00 for each three months )

Accounts charged four times a year.

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ASSOCIATE SINGLE/YOUNG FAMILY MEMBERSHIP ( $ 30.00 for each month )

Accounts charged once a month.

Email

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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