Adult Couple

Membership Application for Adult Couple

We hereby request becoming members of the Rockin’ Squares!
Please create club badges using our first names below.

Please accept my check for dues made payable to Rockin’ Squares. (QR code available on request.) Check #: *

* Indicates required field

Name 1 *

First

Last

Name 2 *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Alt. Phone Number *

Birthday of 1st Adult *

Birthday of 2nd Adult *

Email 1 *

Email 2 *

We hereby give permission for our phone numbers, birthdates (not year), and e-mail addresses to be shared with members of the club. *

YES NO

I also understand photos and videos may be taken during classes and at dances which may be used in the future for marketing purposes and give our permission for these photos and video to be shared within the square dance community. *

YES NO

Dancer 1's Signature *

Dancer 2's Signature *

(By typing names here acknowledges electronic signature)

Date Signed: *

EMERGENCY CONTACT INFO

Emergency Contact Name *

First

Last

Relationship *

Emergency Contact Phone *

Emergency Contact Email *

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