Club 55 Membership Form
Club 55 would like to update our membership form. If you can please take the time to fill out this form with your current information it would help us out tremendously.  We would also like to start a Birthday Club and mention monthly Birthdays.  If you do not want your name mentioned we will not post it but we do want to celebrate some of the little things in life.  Thank you for providing your information!
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Who refered you?
Last name, first name *
Spouse/partner
Gender:
Clear selection
Preferred Phone number *
Secondary phone number
Address (City, State, Zip Code) *
Email Address:
Date of Birth
MM
/
DD
/
YYYY
Anniversary:
MM
/
DD
/
YYYY
Emergency contact Name *
Emergency contact Phone *
Emergency contact Relationship
Secondary Emergency contact Name
Secondary Emergency contact Phone
Secondary Emergency contact Relationship
Preferred Hospital
Allergies
Health Concerns: include any special medical or personal information you would want us to know
Comments:
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