REGISTRATION FORM -The ROC's Membership Program

The ROC's Membership Program

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Membership Level
Parent Full Name*

First NameLast Name
Parent Full Name

First NameLast Name
Student Full Name*

First NameLast Name
Student Age & Date of Birth*

Student AgeStudent Date of Birth
Student Full Name

First NameLast Name
Student Age & Date of Birth

Student AgeStudent Date of Birth
Student Full Name

First NameLast Name
Student Age & Date of Birth

Student AgeStudent Date of Birth
Address

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Street Address Line 2

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Phone Number

Area CodePhone Number
Email Address*
Emergency Contact Full Name
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Are You Interested in Being a Mentor in our Mentorship Program?
Occupation/Professional Experience
Comments
Testimonials
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My Products

General Membership (Annual)$100.00

Contributing Member (Annual)$500.00

Supporting Member (Annual)$1,000.00

Sponsoring Member (Annual)$5,000.00

Sustaining Member Bronze (Annual)$10,000.00

Sustaining Member Silver (Annual)$17,000.00

Sustaining Member Gold (Annual)$25,000.00

Teen Membership Program (Per Term)$350.00

Quantity

PARTY FOR A PURPOSE Member All Inclusive Tickets for Family/Group of 4 to Silent Disco events all year!$450.00

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