Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

Date of Birth *

MM

DD

YYYY

Time of birth

if known

Hour

Minute

Second

AM PM

I am a: *

Cohen

Levi

Yisrael

Not Sure

I am Jewish by *

If converted please email your conversion certificate to info@jewishbattersea.com

Birth

Conversion

Was your mother or Grandmother converted? *

No

Yes

Marital Status *

Single

Married

Divorced

Widowed

Anniversary date?

If married please email your ketubah to info@jewishbattersea.com

MM

DD

YYYY

Spouse's Name

First Name

Last Name

Spouse's date of birth

MM

DD

YYYY

Spouse's time of birth

Hour

Minute

Second

AM PM

Spouse's Mother's Hebrew name

First Name

Last Name

Spouse is Jewish by?

If conversion please email conversion certificate

From Birth

Conversion

Was their mother or grandmother converted?

Yes

No

Are any of your children adopted?

Yes

No

Which Membership level would you like to join? *

Annual payment is due on signup and then each year in January. *You can choose to join the burial scheme in addition to membership or irrespective of membership. From age 45 and above, there is a one-off joining fee to pay in order to join the scheme. This increments with age and is only paid upon entry to the scheme, please ask the office to view the sliding scale.

Single without burial £500

Family without Burial - £900

Single with burial - £630

Family with burial - £1,030

Burial society only - £130

I would like to pay *

Annually

Monthly

I would like to pay by: *

Card

Bacs

Direct debit

Paypal

I declare that the aforesaid particulars given by me are correct. I understand that in the event of any question arising at any time in regard to my personal status in Jewish law of myself, or my spouse or any of my Children, and my eligibility to the WCF burial scheme, the decision of the Office of the Chief Rabbi shall be final. I also agree that Chabad of Battersea may use my information according to the privacy policy which can be found at Jewishbattersea.com/privacy-policy and copies of the documents I supply may be sent to the WCF for their records. *

Yes