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Class A Membership Form

By landline - Posted on 05 April 2011

Please complete the following form so that we can update your membership records.

Name: *

The Certificate Holder's Full Name

Spouse Name:

The Certificate Holder's Spouse's Name

Address: *

Current address where correspondence may be sent

City: *

State: *

Zip: *

Home Phone Number:

Cell Phone:

Email Address 1: *

Your primary email address

Email Address 2:

A spouse's or secondary email address

Child #1:

Child's name, under age 22

Child #1 Relationship:

How the child is related to the Certificate Holder

Child #1 Birthday:

Child #2:

Child #2 Relationship:

How the child is related to the Certificate Holder

Child #2 Birthday:

Child #3:

Child's name, under age 22

Child #3 Relationship:

How the child is related to the Certificate Holder

Child #3 Birthday:

Child #4:

Child #4 Relationship:

Child #4 Birthday:

Child #5:

Child #5 Relationship:

Child #5 Birthday:

Child #6:

Child #6 Relationship:

Child #6 Birthday:

Child #7:

Child #7 Relationship:

Child #7 Birthday:

Add-on Member 1 Name:

Add-on Seasonal Memberships are:
$120 if 13th Birthday is prior to 16 May 1998
$80 for under 13

Add-on Member 1 Relation:

Babysitter, nanny, grandparent, child care child, etc.

Add-on Member 1 Birthday:

Add-on Member 2 Name:

Add-on Seasonal Memberships are:
$120 if 13th Birthday is prior to 16 May 1998
$80 for under 13

Add-on Member 2 Relation:

Babysitter, nanny, grandparent, child care child, etc.

Add-on Member 2 Birthday:

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