AJRA Online Membership Form

AJRA Online Membership Form
Name

First Name Last Name
Email
example@example.com
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Parent Name

First Name Last Name
Social Security Number *
Gender
Family Memberhip ONLY
Family Memberships are for families living under the same roof.
Family Membership ONLY
NAME OF FAMILY MEMBER THAT MEMBERSHIP WAS PAID UNDER

My Products

AJRA 2022-2023 Membership 2023-2023 Membership

Choose One	Choose One	Price
Single Membership		$ 150.00
Family Membership		$ 225.00
Add On Family Member To PD Membership		$ 0.00

Item subtotal: $ 0.00

T- Shirt Size

Free Shirt Size

Subtotal

$ 0.00

Tax

$ 0.00

Total

$ 0.00

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.