Please fill out the following information as completely as possible.
*Required Fields
*First Name:
*Last Name:
Spouse's Name:
*Email:
*Phone Number:
*Address:
Affiliation:
*Child's First Name:
Child's Last Name:
Child's Gender:
*Child's Birthdate:
Regional Center:
School District:
Sibling Name(s)
and Age(s):
membership
PAYMENT INFORMATION
Annual Membership Dues: $45
(for families this fee covers all adults and children in your household)
*Payment Method:
Paying by cash or check:
After filling out and submitting this form please send cash or a check (payable to Club 21)
Club 21 PO Box 91790
Pasadena, CA 91109If you have question or need more information, please contact us at info@clubtwentyone.org.
