New Member Application

Member Application

2013/2014 School Year Fees: $40 with polo and $30 without polo

Single Semester Fee: $25 with polo or $15 without polo

Full Name

First NameLast Name

Year in School

E-mail

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Cell Phone

Area CodePhone Number

Birth Date

MonthDayYear

Cultural Background (for statistical purposes only)

How did you find out about LMSA Plus?

Shirt Size

I understand that all my personal information is to be kept confidential and information is only to be used for LMSA Plus purposes and/or related activities. Applications can also be printed and dropped off at the Health Professions Office at UH 223 or sent via email to lmsa.plus@fullerton.edu. If you have any questions, please feel free to contact Elizabeth Rios or Natalie Oseguera via the LMSA plus email address. Thank you!