FoDLA Membership form

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Please provide the following information to become a free member of FoDLA (www.fodlagroves.org)
This contact information will NEVER be shared or sold. It's only for sending out invites to the members-only forums, and other direct communications from FoDLA to you.

Email *

Last Name *

First Name *

Nickname/Religious Name (if any)

Address 1: *

Address 2:

City *

State *

Zip *

Phone#

Date of Birth (members MUST be over 18) *

YYYY

The following info may be released to other members (please check all the apply) *

None (all Confidential)

Legal Name

Nickname/Religious name

Street Address

Email Address

Phone Number

Required

The Following info may be released to NON-Members (check all that apply) *

None (All confidential)

Legal Name

Nickname/Religious Name

Street address

Email Address

Phone#

Required

By Entering my name below, I affirm that I am a polytheist Pagan seeking membership and I support the FoDLA Founding Vision [http://www.fodlagroves.org/founding-vision/] (Required) *

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