Membership Application Form

Membership Application

To apply for membership please complete all questions.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Home Number

Area CodePhone Number
Cellular Number

Area CodePhone Number
Emergency Contact Person
Primary Number

Area CodePhone Number
Secondary Number

Area CodePhone Number
Responsibilities: I assume the risk for any injury I might suffer in any program at the Dietert Center facilities and grounds. I also understand that by participating in any program, the instructor, staff and the Center are not responsible for personal injury or accident.

Should my photo be taken at any of the Center activities, they have my permission to use it for publicity purposes.
We have found that many members increase their enjoyment at the Center through volunteer activities. Are you interested in knowing more about the opportunities to volunteer?
Volunteer Activities

YesNo
Demographic Data

Check all that apply - for internal use ONLY - NEVER shared
How did you hear about us

CatalogInternetNewspaperRadioFriend
Have you been to Dietert before

YesNo
Gender

MaleFemale
Date of Birth

MonthDayYear
Date of Application
Membership Options
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1 Year Membership$35.00

6 Month Membership$25.00

Lifetime Membership$500.00

Claim It Club Monthly Member - Attend all "Weekly" classes and activities for this one low monthly fee. This is only valid during the month you sign up.$35.00
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