Lakewood Ranch Republican Club Membership Application

Thank you for your interest in becoming a member of the Lakewood Ranch Republican Club. Please complete the application below in its entirety and submit your payment. Upon receipt we will confirm party affiliation of all new member applicants and send you a confirmation.
Application Date

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Please note that this person will be considered the owner of a Couple/Family Membership.
Couple/Family Membership Owner?

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please enter your current cellphone number*
Please enter a valid phone number.
Now enter your Home Phone number.
Please enter a valid phone number.
Please enter your Date of Birth.*

MonthDayYear
Date
Are you a current Member?

YesNo
Are you a registered Republican?*

YesNo
Please indicate the type of Membership for which you are applying.*

Individual - $15 annual membershipCouple/Family - $25 annual membership
How many Family Members do you wish to add to your Couple/Family membership?

123
Please enter the Name of Family Member 1.

First NameLast Name
Please enter the Email of Family Member 1.
example@example.com
Please enter the Date of Birth for Family Member 1.

MonthDayYear
Date
Please enter the Name of Family Member 2.

First NameLast Name
Please enter the Email of Family Member 2.
example@example.com
Please enter the Date of Birth for Family Member 2.

MonthDayYear
Date
Please enter the Name of Family Member 3

First NameLast Name
Please enter the Email of Family Member 3
example@example.com
Please enter the Date of Birth for Family Member 3.

MonthDayYear
Date
Please enter the Name of Family Member 4

First NameLast Name
Please enter the Email of Family Member 4
example@example.com
Please enter the Date of Birth for Family Member 4.

MonthDayYear
Date
Membership Owner
Has anyone referred you to the Club?

YesNo
Please enter the name of the person who referred you.

First NameLast Name
Check payable to "LWRRC". Submit check to :

Charlotte Madar

Treasurer

14631 Castle Park Terrace

Lakewood Ranch, FL 34202
Please note: As a Chartered Club authorized by the Republican Party of Florida, members are required to be a registered Republican subject to verification.
Should be Empty: