Membership Category Change Form
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List individuals you would like to add/delete (Adult 18+ Years, MAX of 5 adults on membership and must live in same household)
First Individual
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Adult/Child
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Birth Date
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Second Individual
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Full Name
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Adult/Child
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Adult
Child
Birth Date
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Third Individual
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Child
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Fourth Individual
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Adult/Child
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Adult
Child
Birth Date
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Sex
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Male
Female
If adding adult, verify income and choose total household income for membership
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Category 1
Category 2
Category 3
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Comments:
By signing (typing) my name below, I acknowledge that I am the primary account holder of the membership and that the above information is correct. I understand that it will require 30 days notice prior to the next draft date to become effective. Confirmation will be sent to the email address provided above.
*
Staff Use Only:
If this is an addition/ upgrade, please ask MOD to transfer at desk and receipt payment for the added member(s) before clicking submit.
Member #
*
Current Membership: (2A2C, etc.)
*
New Membership:(1A, etc.)
*
Current Draft Date
*
Please Select
1st
8th
15th
23rd
Employee signature
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