1.Name & Mailing Address

Name

Address

Address 2

City/Town

State/Province

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP/Postal Code

Email Address

Phone Number

2.What is your age?

Under 18 (parent permission needed)

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

3.Would you like to listed on the Atomic Betty Club Roster?

Yes

No

Maybe

*4.Emergency Contact Information(Required.)

Name

Phone Number

5.Please list any allergies or medical conditions that we need to be aware of and support.

6.I agree to keep Atomic Betty Club Codes protected, as these are for paying members.

Yes

No

Does Not Apply (non-paying membery)

*7.Atomic Betty Club Waiver
I have read and agree to the terms listed in the above link. 
This is also posted on the Atomicbetty.club website.(Required.)

Yes

No

8.I am a new member to Atomic Betty!

Yes

No