New Member Application Form
Please fill out this form. The Email address that you enter here will be used by Chi Am Circle to send you program notifications, Newsflashes, and our Newsletter.  After you fill out the form and press the "Submit" button, the Google form will acknowledge that your submission is successful, the link to the PayPal payment page will be made available. Please click the link to pay your membership dues. Thank you.


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Email *
What is your name (Last, First)? *
Main Contact Number (999-999-9999)? *
Please enter your number with area code first, followed by the 7-digit number separated by hyphens
Cell Phone Number (999-999-9999)?
Preferred method of contact in addition to email? *
Home Address (e.g. Number, Street, Apt #, or PO Box #)? *
Home Address (City)? *
Home Address (State)? *
Please enter the two letter State Code
Home Address (Zip code)? *
Spouse name if applicable (Last, First)
Emergency Contact Name (Last, First) *
Relationship to Emergency Contact
Emergency Contact Phone Number (999-999-9999) *
Alternate Emergency Contact Name (Last, First)
Person to call if the Primary emergency contact cannot be reached
Alternate Emergency Contact Phone Number (999-999-9999)
Photo Consent - "Whenever present at any Chi Am Circle Club hosted or sponsored event, I give permission to Chi Am Circle Club to use my name, photographs, electronic media images or recordings for any Chi Am Circle Club publication, website, publicity, social media or promotional purposes.  I understand that I may revoke this authorization at any time by notifying Chi Am Circle Club in writing. The revocation will not affect any actions taken before the receipt of this written notification.   This photo release consent takes effect when I sign.  In lieu of my eSignature, the “Yes”  or “No” box below serves as my signature. *
Would you allow your home address (Number, Street, Apt #, PO Box etc..) to be included in the Membership Directory? *
Birthday Info (MM/DD)?
Please provide your birth month and birth day only
Person who introduced you to Chi Am Circle (Last, First)
Interests - Please let us know your interests.  Please check all that apply.
Skills - Please let us know your skills. Please check all that apply.
Interest in knowing more about Chi Am Circle Scholarship Sponsorship?
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A copy of your responses will be emailed to the address you provided.
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