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Membership Census
Please fill out all the areas below even if you believe we have the updated information.
This form is for a single individual and not the household.
Please complete 1 form per "member" living in your household.
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Birthday Month
*
Choose
January
February
March
April
June
July
August
September
October
November
December
Birthday Day
*
Choose
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Age Group
*
Child
Teen
Young Adult
Mature Adult
Young at Heart
Required
Member Email (If you are completing this form for someone else please enter
their email address
. If they do not have one please enter
na@noemail.com
)
*
Your answer
Phone Number
*
Your answer
Street Address
*
Your answer
City
*
Your answer
State (in Abbreviated form ie... NY, FL, NJ)
*
Your answer
Zip Code
*
Your answer
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