1.First Name

2.Last Name

3.Do you meet these qualifications for a free membership?

· A student OR

· In need for financial help OR

· Be a new member (or lapsed member from 2 years prior)

· Must attend three meetings initially

· Must attend at least 3 meetings after receiving said membership

Yes

No

4.Email Address

5.Who referred you? (You can right N/A if its no one)