JACS Membership Form

JACS: Jewish Alcoholics, Chemically Dependent Persons, and Significant Others

JACS MEMBERSHIP FORM - 2011
[Download Membership Form]

JACS is supported by institutions, individuals, and membership dues. Half of our support comes from membership fees and contributions — which directly support all of JACS services, providing outreach and education to the Jewish community about addiction and recovery. Annual dues are:

$36 for an individual;
$72 for a family;
$75 for a professional;
$125 for an Institution;

Simply print this form and mail it with your payment (Check/Money Order/or Credit Card information) to: JBFCS/JACS, 135 West 50th Street, 6th floor, New York, NY 10020

Name:	_______________________________________
Organization:	_______________________________________
Address:	_______________________________________
City, State Zip:	_______________________________________
Home Phone:	_______________________________________
Work Phone:	_______________________________________
Cell Phone:	_______________________________________
Email:	_______________________________________
	(Email is only used for sending notices and updates)

Please consider an additional donation to JACS.

MEMBERSHIP DUES*			*ADDITIONAL CONTRIBUTIONS*
$ 36	[ ]	Individual	$10,000	[ ]	Corporate Sponsor
$ 72	[ ]	Family	$5,000	[ ]	Teen Scholarship Fund Sponsor
$ 75	[ ]	Professional	$1,000	[ ]	Benefactor
$125	[ ]	Institutional	$500	[ ]	Patron
			$275	[ ]	Donor
			$100	[ ]	Sponsor
			$50	[ ]	Friend
			$18	[ ]	Chai" Donation
			$_____	[ ]	Retreat Scholarship Fund**

* JACS Retreats are for Members only.
** Provides scholarships and loans to qualified individuals to enable them to attend JACS retreats.

TOTAL AMOUNT ENCLOSED: $_______

Payment Method: Check #_______ | Money Order #_______ | Credit Card

Credit Card: (Circle One) AMERICAN EXPRESS | DISCOVER | MASTER CARD | VISA

Card Number: ______________________________ EXP MM/YR: ____ / 20____

Cardholder Name: ______________________________