Adult Single

Membership Application for Adult Single

I hereby request becoming a member of the Rockin’ Squares!
Please create club badge using my first name below.

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

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Alt. Phone Number *

Birthday *

Email *

I hereby give permission for my phone, birthdate, (not year), and e-mail 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 my permission for these photos and video to be shared within the square dance community. *

YES NO

Dancer's Signature *

(By typing name 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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