BX HQ Member Registration

Member Registration
Hangouts at BX HQ will officially kick off weekly in December!

December 1st, 8th, 15th and 22nd

3:30 - 5:30 PM
MEMBER INFORMATION
Member Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Member Email
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
FINANCIAL RESPONSIBILITY
Is the member listed above the person financially responsible for the membership?*

YesNo
Billing Contact*

First NameLast Name
Relationship to Member*
E-mail*
example@example.com
Phone Number:*
EMERGENCY CONTACT
Who should be contacted in case of an emergency?*

Billing Contact (listed above)Other
Emergency Contact*

First NameLast Name
Relationship to Member (EMG)*
For emergencies only
E-mail*
For emergencies only
Phone Number*
For emergencies only
Additional Notes:
How did you hear about us?*
Should be Empty:

MEMBER INFORMATION