Chochmat HaLev 2018-2019 Membership Form
I / we are joining as a *
Pledge Amount and Payment
2018-2019 Dues Rates:

Sustaining Community Member
o One-adult household $200+ /month
o Two-adult household $400+ /month

Supporting Community Member
o One-adult household $110+ /month
o Two-adult household $210+ /month

Conscious Community Member
o One-adult household: $75+ /month
o Two-adult household: $140+ /month
o Under 40 years old: One-adult $40 /month, Two-adult $75 /month

I / we commit to the following monthly membership dues pledge *
Please type in the MONTHLY amount of your pledge.
Your answer
Household Information and Members
Mailing Address : Number, Street & Apt (if applicable) *
Your answer
Mailing Address City, State, Zip *
Your answer
Home Phone *
Please list your home phone number
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Adult Member One *
(Last name, First Name)
Your answer
Member One cell number
Please list Member One's cell number
Your answer
Member One email *
Please list Member One's email address
Your answer
Member One's birthdate *
(mm/dd/yyyy)
Your answer
For Two Adult Membership:
Adult Member Two
(Last name, First Name; must be completed for a 2 adult membership)
Your answer
Member Two cell number
Please list Member Two's cell number
Your answer
Member Two's email
Please list Member Two's email address
Your answer
Member Two's birthdate
(mm/dd/yyyy)
Your answer
Children Under 21
Children under 21 are included in the membership
Child One
(Last name, first name)
Your answer
Child One Birthdate
(mm/dd/yyyy)
Your answer
Child Two
(Last name, first name)
Your answer
Child Two Birthdate
(mm/dd/yyyy)
Your answer
Child Three
(Last name, first name)
Your answer
Child Three Birthdate
(mm/dd/yyyy)
Your answer
Additional Children
Please list Firstname, Lastname and birthdate for all additional children
Your answer
Urban Shtetl - Is your family interested in the Urban Shtetl Family Program?
Volunteer Commitment
Volunteers are crucial to Chochmat Halev, and volunteering is a great way to become more connected in the Chochmat community.
Committees
Please indicate if you would be willing to serve on any of the following committees:
Tasks
Please indicate if you have skills and/or interest in the following:
You're almost there! Please contact the office at 510-704-9687 to set up payments. THANK YOU FOR BECOMING A MEMBER!
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