Membership Registration
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Preferred Pronouns
He / Him
She / Her
They / Them
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
My Products
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Individual Membership
Personal Membership for 1 person
$
75.00
Quantity
1
2
3
4
5
6
7
8
9
10
Item subtotal:
$
0.00
Civic Group Membership
Membership for Business or Civic Group
$
200.00
Quantity
1
2
3
4
5
6
7
8
9
10
Church Membership
Membership for a Church Group
$
270.00
Quantity
1
2
3
4
5
6
7
8
9
10
Credit Card Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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