FCLIR Membership Form 2024-2025

FCLIR Membership Form

Join for November 2024 - May 2025 half year membership.
Please complete both sections of the form below. Starred items are required.
Today's Date*

MonthDayYear
Full Name*

First NameLast Name
I am a*

New memberReturning member
Nickname

SECTION 1. CONTACT INFORMATION
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email*
Check if any of these fields have changed:

AddressPhone numberEmail
How did you hear about FCLIR?

From a friend or colleagueFrom a presentation about FCLIRFrom the FCLIR web siteFrom a flyer or other advertisingOther
Emergency Contact*

First NameLast Name
Emergency Contact Phone*

SECTION 2. DUES AND PAYMENT OPTIONS
Membership Category*

New member, half year: $100Membership assistance for members experiencing financial hardship: sliding scale
(If you select "Membership assistance" above you will see a line where you can select a reduced rate.)
Amount I can pay:
Enter amount in dollars (0 to 250)
Payment will be made by*

myselfanother member
Name of payer

First NameLast Name
Please provide the payer with a copy of your confirmation email (see below.)
I will pay*

onlineby check
Please make your check payable to "Five Colleges, Inc." and write "FCLIR membership" in the memo line. Mail your check to

Five College Learning in Retirement
P.O. Box 105
North Hatfield, MA 01066
Calculation
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Online payment
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Dues to be paid online

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USDFCLIR Membership Dues 2024-2025
When you click the SUBMIT button below, you will be redirected to PayPal to complete your transaction.
Starting in 2025, the Fall and Spring catalogs will be provided as PDFs to all members. If you require a print catalog, please check the box below.
Check here to receive a print catalog
As a member of Five College Learning in Retirement, I recognize that my address, email, and telephone number will appear in the FCLIR membership directory and my photograph may appear in the newsletter or on the website unless I request an exemption in writing.

You may opt to have your address omitted from the membership directory by checking the box below.
Check here to omit your address from the membership directory
Initials*
By initializing this form, I acknowledge that I have read and agreed to the statement above.
When you click the SUBMIT button below, an email confirmation with all the information from the completed form will be sent to the address below. You will be redirected to the thank-you page on our web site with more information. (You may have to click "return to merchant" on the final PayPal page.)
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