Family Information Full Name* Prefix First Name Last Name Home Phone Number 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 Your Details First Name* Hebrew Name I am a* KohenLeviYisroelConvertAdopted Father's Hebrew Name Mother's Hebrew Name Date of Birth* 12345678910111213141516171819202122232425262728293031 Day1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of Birth 123456789101112 Hour001020304050 MinutesAMPM Mobile Number* E-mail* Occupation Marital Status Marital Status* MarriedDivorcedWidowedNever Been Married Synagogue you got married in Date you got married 12345678910111213141516171819202122232425262728293031 Day1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Please send a copy of your Ketuba to [email protected] Date you got Divorced Day Month Year Do you have a "Get" YesNo "Get" Administered by Date "Get" was administered Day Month Year Name of previous spouse Synagogue you got married in Date Spouse Passed away Day Month Year Synagogue you got married in Would you like to add a Spouse/Partner YesNo Full Name* First Name Last Name Hebrew Name My Spouse/Partner is a* KohenLeviYisroelConvertNot JewishAdopted Fathers Hebrew Name Mothers Hebrew Name Birth Date* 12345678910111213141516171819202122232425262728293031 Day1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of Birth 123456789101112 Hour001020304050 MinutesAMPM Mobile Number* E-mail* Occupation Children Would you like to add a child/children* YesNo Child 1 Full Name* First Name Last Name Hebrew Name Select if applicablle ConvertAdopted Date of Birth* 12345678910111213141516171819202122232425262728293031 Day1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of Birth 123456789101112 Hour001020304050 MinutesAMPM Gender* MaleFemale School Attending* Add Another Child?* YesNo Child 2 Full Name* First Name Last Name Hebrew Name Select if applicablle ConvertAdopted Date of Birth* 12345678910111213141516171819202122232425262728293031 Day1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of Birth 123456789101112 Hour001020304050 MinutesAMPM Gender* MaleFemale School Attending* Add Another Child?* YesNo Child 3 Full Name* First Name Last Name Hebrew Name Select if applicablle ConvertAdopted Date of Birth* 12345678910111213141516171819202122232425262728293031 Day1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of Birth 123456789101112 Hour001020304050 MinutesAMPM Gender* MaleFemale School Attending* Add Another Child?* YesNo Child 4 Full Name* First Name Last Name Hebrew Name Select if applicablle ConvertAdopted Date of Birth* 12345678910111213141516171819202122232425262728293031 Day1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of Birth 123456789101112 Hour001020304050 MinutesAMPM Gender* MaleFemale School Attending* Yahrtzeits Would you like to add a Yahrtzeit?* YesNo Yahrtzeit 1 Name of Deceased* First Name Last Name Deceased's Hebrew Name Deceased was a KohenLeviYisroelConvert Deceased's Father's Hebrew Name Deceased's Mother's Hebrew Name Date of Death* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of Death 123456789101112 Hour001020304050 MinutesAMPM Your Relationship to Deceased's* Would You like us to say Kaddish on the Yahrtzeit YesNo Add Another Yahrtzeit? YesNo Yahrtzeit 2 Name of Deceased* First Name Last Name Deceased's Hebrew Name Deceased was a KohenLeviYisroelConvert Deceased's Father's Hebrew Name Deceased's Mother's Hebrew Name Date of Death* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of Death 123456789101112 Hour001020304050 MinutesAMPM Your Relationship to Deceased* Would You like us to say Kaddish on the Yahrtzeit YesNo Add Another Yahrtzeit? YesNo Yahrtzeit 3 Name of Deceased* First Name Last Name Deceased's Hebrew Name Deceased was a KohenLeviYisroelConvert Deceased's Father's Hebrew Name Deceased's Mother's Hebrew Name Date of Death* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of Death 123456789101112 Hour001020304050 MinutesAMPM Your Relationship to Deceased* Would You like us to say Kaddish on the Yahrtzeit YesNo Add Another Yahrtzeit? YesNo Yahrtzeit 4 Name of Deceased* First Name Last Name Deceased's Hebrew Name Deceased was a KohenLeviYisroelConvert Deceased's Father's Hebrew Name Deceased's Mother's Hebrew Name Date of Death* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Time of Death 123456789101112 Hour001020304050 MinutesAMPM Your Relationship to Deceased* Would You like us to say Kaddish on the Yahrtzeit YesNo Notes Membership Options *includes children up to 21 years old Single £300 Per Year£25 Per Month Couple £360 Per Year£30 Per Month Add Burial If you are setting up a Burial Policy - this is done with us through the Federation of Synagogues, we will need some proof of Jewish identity and all new members over the age of 30 are charged a joining fee depending on age. All this can be discussed with the Rabbi for details. All Membership fees or donations can be made in 1 installment or 12 monthly installments. Please tick your desired package and payment option. Up To 29 Years Old Membership + £50 AnuallyMembership + £4 Monthly 30 - 74 Years Old Membership + £85 AnuallyMembership + £7 Monthly 75 - 94 Years Old Membership + £65 AnuallyMembership + £5 Monthly Gift Aid Boost your donation by 25p for every £1 you donate Gift Aid is reclaimed by the charity from the tax you pay for the current tax year. Gift Aid Please tick here if you are a UK Tax Payer and your donations can be counted as Gift Aid. Please Confirm* I am a UK taxpayer and understand that if I pay less Income Tax and/ or Capital Gains Tax than the amount of Gift Aid claimed on my donations in that tax year it is my responsibility to pay any differance Please Confirm* I want to Gift Aid any donations I make in the future to TZIVOS HASHEM UKI want to Gift Aid any donations made in the past four years to TZIVOS HASHEM UK Signed by* Prefix First Name Last Name Areas of Interest At Chabad we offer a wide range of programmes and activities, help us cater for you better by giving us an idea of your areas of interest and events you and your family may be interested in: Adult EducationMums & TotsOccasional CoursesWomens EventsShabbat Childrens ServicesBusiness Lunchtime ClassesSunday Morning Tefillin ClubDaily Shachris MinyanGuest Speaker EventsWeekly ClassesTeen ProgrammesShabbat Morning ServicesComunal Festival CelebrationsHebrew Reading TrainingSingles EventsFriday Night ServicesFamily Friday Night DinnersYouth Activities Confirm your preferred email address for events emails Notes Anything else you want to tell us about your family, interests or needs Proof of Jewishness To accept your application, we require a "Proof of Jewishness". This can be your own Ketuba, your parents Ketuba, a Letter from a recognized Orthodox Beth Din, or something similar Please upload a proof of Jewishness * I have uploaded my proof of JewishnessI will send my proof of Jewishness to [email protected] Consent * I hereby certify that all information given above is true and correct and that I, and all members of my immediate family named herein, are Jewish by birth, or by conversion in accordance with Orthodox Jewish Law (Halacha). Signiture* Prefix First Name/s Last Name Should be Empty: Submit This page uses TLS encryption to keep your data secure.
This page uses TLS encryption to keep your data secure.