FDS Intake-old

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Are You an* This field is required.
Interest
New Member
Renewal
2
How do you identify?
Please Select
Please Select
Lesbian
Bi-Sexual
3
What are your pronouns?
4
If an interest, would you like to learn more about this life changing journey other women like yourself have embarked on?* This field is required.
YESNO
5
How did you hear about us?* This field is required.
A Swan
Instagram
Community Event
Other
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Name* This field is required.
Prefix
First Name
Middle Name
Last Name
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Date of Birth* This field is required.
Date
Month
Day
Year
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Primary Phone Number* This field is required.
Please enter a valid phone number.
10
Secondary Phone Number
Please enter a valid phone number.
11
Email* This field is required.
example@example.com
Confirm Email
12
Emergency Contact* This field is required.
First Name
Last Name
13
Emergency Contact Phone Number* This field is required.
Please enter a valid phone number.
14
Occupation* This field is required.
15
Primary Mode of Contact* This field is required.
Call
Text
Email
16
Permission to use your PICTURE in publications and/or on the website?* This field is required.
Yes
No
17
Permission to use your NAME in publications and/or on the website?* This field is required.
Yes
No
18
Are you ready to create a lasting legacy and build bonds with other likeminded women?* This field is required.
YESNO
19
Are you committed to serving your community and making lasting changes?* This field is required.
YESNO
20
Please upload a current picture* This field is required.
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Select files to upload
Max. file size: 10.6MB
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What can you contribute to the organization?* This field is required.
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Ok
Ok
22
Are you interested in a leadership role?* This field is required.
Yes
No
Maybe in the future
23
What are your expectations?* This field is required.
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Ok
24
Are you affiliated with another organization? * This field is required.Example: Delta, AKA, Eastern Star, etc.
YESNO
25
Name Of Organization?* This field is required.
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Are you able to make a full commitment to both? If so, how? * This field is required.
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Ok
Ok
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Femmes of Distinction Society is a social service organization that extends the opportunity for membership to women who are...

1. A 25 year or older Professional

2. Women who identify as Lesbian or Bisexual

3. Willing to Actively give back to their respective communities

4. Looking to bond with like-minded women from various walks of life across South Florida

5. Be able to pay application fee and annual fees.

Everyone interested in membership must complete an initial Interest application. Someone from our Membership Intake Department will contact you for further details.
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Please Initial agreeing that all above information is true and correct.* This field is required.
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