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Member Registration Form

Please note that this is a base membership. Additional forms are required for members wishing to become gym members or participate in the lunch program.

Member Information

First Name *

Nickname

Last Name *

Last 4 Digits of SSN

Date of birth *

Address *

City *

State *

Postal code *

Phone *

Secondary Phone

Email

Mailing Address (If different)

Demographics*

Gender

Female

Male

Race/Ethnicity

White, Non-Hispanic
White, Hispanic
Black/African American
Asian/Pacific Island
Native American/Alaskan Native
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Household Information*

Marital Status

Married/Partner
Single
Widowed
Divorced
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Veteran

Yes
No
Spouse of Veteran
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Household Income (Monthly)

$

Income Type

Individual

Couple

*This information is collected for grant applications and reporting.

Emergency Contact Information

Emergency Contact Name

Relationship to Member

Emergency Contact Phone Number

I would like to receive The Estuary Gazette:

(If choosing to receive the gazette by email, please make sure your email is included in the "Email" field above)

by Mail (requires $10 annual postage fee)

by Email

Captcha

Phone : 860-388-1611

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