Caring & Sharing Membership Application

*Indicates Required Fields

To be completed by student and parent/guardian.

Note: Membership dues are non-refundable and non-transferable.
1. Girl's Information
*Girl First Name:
*Girl Last Name:
*Age         Grade Level
   
Date of Birth:
*Primary Phone Number:
*Name of your School:
*Email Address:
*Confirm Email Address:
*Street Address:
Apt/Unit:
*City:
*State    *Zip
   
*County:
2. Parent/Guardian Information
*First Name:
*Last Name:
*Primary Phone Number:
*Email Address:
*Confirm Email Address:
*Who does the student live with?
Mother   Father  Both  Guardian
If address is the same check here
and proceed to Question #3
*Street Address:
Unit/Apt:
*City:
*State    *Zip
   
*County:
*Parent's Employer:
Work Phone Number:
3. Marketing Question
Please help enhance our marketing efforts. How did you first hear about Caring & Sharing?

Word of Mouth
Website or Search Engine
Brochure
Other  
4. Getting to know you.
List one or two your hobbies or interests:
Hobby/Interest 1:
Hobby/Interest 2:
List one or two of your awards or achievements:
Award 1:
Award 2:
List one or two teams or organizations that you are actively involved in:
Group 1:
Group 2:
What are areas of self improvement that you are considering?
(i.e., attitude, grade, self-esteem, behavior, etc.)
Area 1:
Area 2:
5. Why would you like to become a member of Stir It Up Girls?
 Characters Left
6. Caring & Sharing Member Policy:

Click Here to review and download the Caring & Sharing Member Policy.

*I have read and agree with the Caring & Sharing Member Policy.
Image Verification:
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