Annual Membership Application

Annual Membership Application

Wicen's Educational Sport Center, Inc.
Today's Date*

MonthDayYear
New Application OR Renewal Application (select one)*

New ApplicationRenewal Application
Membership Type (select one)*

REGULAR - SINGLE Adult (age 18+) Fee $200REGULAR - FAMILY: Self, Adult Co-Member + up to 4 children (less than age 18) Fee $275LEO/MIL/VET/SR (age 65+)/First Responder - SINGLE ADULT (Age 18+) Fee $175LEO/MIL/VET/SR (age 65+)/First Responder - FAMILY: Self, Adult Co-Member + up to 4 children (less than age 18) Fee $250
PRIMARY MEMBER: Full Name *

First NameMiddle NameLast Name
PRIMARY MEMBER: Current Age (MUST BE AGE 18+)*
PRIMARY MEMBER: Date of Birth*

MonthDayYear
PRIMARY MEMBER Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
PRIMARY MEMBER: E-mail*
example@example.com
PRIMARY MEMBER: Phone Number*

Area CodePhone Number
PRIMARY MEMBER: Driver's License # or other approved form of ID*
IF SINGLE MEMBERSHIP, SKIP TO THE BOTTOM FOR PAYMENT AND CHECKOUT.

IF FAMILY MEMBERSHIP, COMPLETE THE FOLLOWING AS APPLICABLE.
CO-MEMBER (AGE 18+): Full Name

First NameMiddle NameLast Name
CO- MEMBER: Current Age (MUST BE AGE 18+)
CO-MEMBER: Date of Birth

MonthDayYear
CO-MEMBER: Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
CO-MEMBER: E-mail
example@example.com
CO-MEMBER: Phone Number

Area CodePhone Number
CO-MEMBER: Driver's License # or other approved form of ID
IF FAMILY MEMBERSHIP WITHOUT CHILDREN, SKIP TO THE BOTTOM FOR PAYMENT AND CHECKOUT.

IF FAMILY MEMBERSHIP WITH CHILDREN, COMPLETE THE FOLLOWING AS APPLICABLE.
CHILDREN - up to 4 children per Family Membership

CHILDREN MUST BE LESS THAN AGE 18 AT TIME OF MEMBERSHIP APPLICATION
CHILD #1 (LESS THAN AGE 18): Full Name

First NameMiddle NameLast Name
CHILD #1: Current Age (MUST BE LESS THAN AGE 18)
CHILD #1: Date of Birth

MonthDayYear
CHILD #2 (LESS THAN AGE 18): Full Name

First NameMiddle NameLast Name
CHILD #2: Current Age (MUST BE LESS THAN AGE 18)
CHILD #2: Date of Birth

MonthDayYear
CHILD #3 (LESS THAN AGE 18): Full Name

First NameMiddle NameLast Name
CHILD #3: Current Age (MUST BE LESS THAN AGE 18)
CHILD #3: Date of Birth

MonthDayYear
CHILD #4 (LESS THAN AGE 18): Full Name

First NameMiddle NameLast Name
CHILD #4: Current Age (MUST BE LESS THAN AGE 18)
CHILD #4: Date of Birth

MonthDayYear
SELECT MEMBERSHIP TYPE AND CHECKOUT *
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REGULAR MEMBERSHIP: Single$200.00
Yearly membership for ONE person age 18+

Quantity

REGULAR MEMBERSHIP: Family$275.00
Yearly membership for any 2 persons age 18+ and up to 4 children less than age 18

Quantity

LEO/MIL/VET/SR (age 65+)/1st RESP MEMBERSHIP: Single$175.00
Yearly membership for LEO/MIL/VET/SR (age 65+)/1st RESPONDER - ONE person age 18+

Quantity

LEO/MIL/VET/SR (age 65+)/1st RESP MEMBERSHIP: Family $250.00
Yearly membership for LEO/MIL/VET/SR (age 65+)/1st RESPONDER - For any 2 persons age 18+ and up to 4 children less than age 18

Quantity

Total $0.00
Enter the message as it's shown (without the strike through line)*
PRESS "SUBMIT" TO CONTINUE TO THE PAYMENT OPTIONS AND TO COMPLETE YOUR REGISTRATION:
Within a few days following submission of this form, you will receive an email from wicenshootingrange@yahoo.com , confirming the status of your application. Please check your junk or spam mail in case our message is received in that folder.

If you pay with a Credit Card, your transaction will appear on your statement as "PAYPAL #PA 402-935-7733 CA"

IF YOU ARE PROHIBITED FROM PURCHASING OR POSSESSING A FIREARM DUE TO STATE OR FEDERAL LAW, YOU ARE NOT ALLOWED ON THE PROPERTY.
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