Date:

Member Status: Member Regular Attender (Non-Member)

Name:

Date of Birth:

Street Address: City, State, Zip:

Home Phone #: Work Phone #: Cell Phone #:

Yes No May we use your Work Phone # to contact you, if neccessary?

Yes No May we use your Cell Phone # to contact you, if neccessary?

Email:

FAMILY INFORMATION:
(Please provide information for any other family members who live at the same address listed above. For any family at a different address, please fill out a separate form.)

Spouse Name: Spouse Date of Birth:

Child 1 Name: Child 1 Date of Birth:

Child 2 Name: Child 2 Date of Birth:

Child 3 Name: Child 3 Date of Birth: