BW4HL Registration Form

BW4HL Registration Form

BW4HL Registration Form
Name*

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

Street Address

Street Address Line 2

CityState

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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Sister
I live in Iowa.

$25.00



Sister Friend
I don't live in Iowa but have a connection to the Greater Des Moines area.

$25.00



Sister's Keeper
My membership + sponsored membership for another sister.

$50.00



Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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