Senior Optimist Club New Member Application 950 New Member Application Senior Hidden Member Status Current MemberIn ReadingsMoved AwayChanged JobsLost InterestStopped PayingDeceasedNo Reason for ending membership Member status or reason for leaving the club if no longer a member. Payment Status Value Not SetCompletedFailed Inducted Enter date inducted Reading1 Enter date of first reading Reading2 Enter date of second reading Reading3 Enter date of third reading Board Appproved Enter date of board approval Ended Approximate last day of membership Item Name Name * Name First First Last Last Home Address * Home Address Home Address Home Address City City State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Code Zip Code Email * Home Phone Cell Phone * Date of Birth Membership Type * St. Leonard Optimist Club ($120/year includes monthly campus meeting- attend Yankee Trace lunch for $10) Enclave Optimist Club ($120/year includes monthly campus meeting) Only the Application Fee is due today. You will be billed later for your membership. Photo Drop a file here or click to upload Choose File Maximum file size: 8MB Our member handbook includes headshots of members. Completed application must be accompanied by $60 application fee. Individuals who have committed offenses against children may be denied membership and/or have their membership revoked. Application Fee This covers initial expenses. Method of Payment Credit Card PayPal Check You will be redirected to PayPal to complete your payment after submitting this form. Payment Signature * signature keyboard Clear Date Captcha Future Ideas Submit If you are human, leave this field blank. Δ
