Club Membership Registration Form

“✨ Libertine Membership Form ✨ ”

Join the Inner Circle of Kink Café
We are delighted to have you join our (optional but premier) dining club, which is for the mature crowd with discerning taste buds.

Now that Kink Café opens its doors to all curious adults, membership becomes your VIP reservation to a world of indulgence. It's optional, but the Libertine experience comes with exclusive perks, private privileges, and the satisfaction of knowing their support fuels I SURVIVED Inc, our nonprofit mission empowering survivors of sexual violence.

🎭 Libertine Perks
As a Libertine, you unlock:
- Priority reservations
- Special pricing
- Private hours access
- Exclusive events
- Mission impact funding I SURVIVED Inc
I confirm I am 30 years old or older (required for membership)
Name*

First NameLast Name
Preferred Pronoun*

She/HerHe/HimThem/They
E-mail*
example@example.com
Mobile Number**
*Message and data rates may apply.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Current Age:
Where did you hear about us?

A Friend or colleagueFacebookIGOther (please enter below)
Preferred way to contact*

TextEmailBoth
💎 Membership Options
Choose your level of indulgence:

-Monthly Membership – $10/month
-Annual Membership – $105/year (save $15)

(Libertine donations are tax-deductible and directly fund I SURVIVED Inc programs.)

“Thank you for considering membership. Whether you choose to join or dine, you stand with us.”

TERMS & CONDITIONS

The privacy and safety of Kink Café and our Guests are paramount, and confidentiality is required of all Members, Guests, Performers, Employees, and Officers. To participate in any Kink Café Dining Event, I hereby agree to the following:
1. I will not disclose identifying information of any Kink Café Member, Guest, Participant, Performer, Employee, or Officer to the public.
2. I will not use or attempt to use photography or video recording at a Dining Event unless I am given express permission by Kink Staff.
3. I will treat everyone with respect.
4. I will not touch performers without consent.
5. I will immediately notify Kink Cafe' Security or Staff any time I become aware of or have reasonable cause to suspect that anyone's safety or ability to consent is at risk.
6. I will not bring any guests under 21 years of age.
7. I will not bring more than 3 guests to dine with me.
8. I acknowledge that I am responsible for the behavior of my guest(s).
9. I acknowledge that any violation of Kink Cafe's Terms & Conditions will result in immediate removal, without refund, and a permanent ban from all future Events.
10. There are no refunds.
Terms & Conditions Acknowledgment*

I understand that Libertine Membership is optional, and my contribution directly supports I SURVIVED Inc’s survivor safety and empowerment programs.I will adhere to the terms & conditions as set forth by Kink Cafe'.
Application Date*

MonthDayYear
Date

My Products*

KINK CARD MEMBERSHIPMonthly

$10.00 for each month

KINK CARD MEMBERSHIPYearly

$105.00 for each year

Credit Card

🔗 Call to Action
“Whether you join our Libertine Circle or simply visit as a guest, you help keep the red rope open for survivors and community alike. Thank you.”
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“✨ Libertine Membership Form ✨ ”

Credit Card