Annual Membership Application

Annual Membership Application - New and Renewals

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

MonthDayYear
2 digit month, 2 digit day, 4 digit year
New Application OR Renewal Application (select one)
Membership Type (select one)
PRIMARY MEMBER: Full Name

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

MonthDayYear
2 digit month, 2 digit day, 4 digit year
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
2 digit month, 2 digit day, 4 digit year
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

MEMBER AND/OR CO-MEMBER MUST BE PARENT OR LEGAL GUARDIAN OF CHILDREN
CHILD #1 (LESS THAN AGE 18): Full Name

First NameMiddle NameLast Name
CHILD #1: Current Age (MUST BE LESS THAN AGE 18)
MUST BE AGE 17 OR YOUNGER
CHILD #1: Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
CHILD #2 (LESS THAN AGE 18): Full Name

First NameMiddle NameLast Name
CHILD #2: Current Age (MUST BE LESS THAN AGE 18)
MUST BE AGE 17 OR YOUNGER
CHILD #2: Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
CHILD #3 (LESS THAN AGE 18): Full Name

First NameMiddle NameLast Name
CHILD #3: Current Age (MUST BE LESS THAN AGE 18)
MUST BE AGE 17 OR YOUNGER
CHILD #3: Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
CHILD #4 (LESS THAN AGE 18): Full Name

First NameMiddle NameLast Name
CHILD #4: Current Age (MUST BE LESS THAN AGE 18)
MUST BE AGE 17 OR YOUNGER
CHILD #4: Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Please verify that you are human
SELECT MEMBERSHIP TYPE AND CHECKOUT
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REGULAR MEMBERSHIP: Single$250.00
Yearly membership for ONE person age 18+

Quantity

REGULAR MEMBERSHIP: Family$300.00
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$225.00
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 $275.00
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

Payment Methods

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Annual Membership Application - New and Renewals

SELECT MEMBERSHIP TYPE AND CHECKOUT *

Payment Methods

SELECT MEMBERSHIP TYPE AND CHECKOUT