BW4HL Registration Form

BW4HL Registration Form
Name*

First Name Last Name
Email*
Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

City State

Zip Code
How did you hear about Black Women 4 Healthy Living?
What are you hoping to get of our membership with Black Women 4 Healthy Living?
Are you interested in serving on a committee or volunteering?
Birthday (optional for Birthday Club)
Month
Day
Shirt Size*
Please choose one.*
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SisterI live in Iowa.
$25.00



Sister FriendI don't live in Iowa but have a connection to the Greater Des Moines area.
$25.00



Sister's KeeperMy membership + sponsored membership for another sister.
$50.00



Total

$0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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

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