Membership Application
*Please Print Legibly*
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Member Number
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For Staff Use Only
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Last Name
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First Name
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Street Address
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Apt or Suite
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City, State, Zip
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Email Address
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Primary Phone
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Secondary Phone
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Date of Birth
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(Emergency Contact #1) Name
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Relationship of Contact
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(Emergency Contact #1) Phone
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(Emergency Contact #2) Name
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Relationship of Contact
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(Emergency Contact #2) Phone
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Membership type
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Monthly Membership
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Yearly Membership
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Employee or Student
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$55
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$600
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General Membership
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$60
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$650
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Minor Membership
13 – 15yrs old
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$30 w/guardian membership
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$300 w/guardian membership
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____ I agree that the membership fee will be processed as a recurring payment on the ________ of each ____________________.
I acknowledge and agree that:
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The information provided is true and correct.
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I have read the membership handbook and agree to abide by the guidelines and policies within.
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MACCLab may send emails to the email address noted above.
Signature of Member: _____________________________________
Date: ____________________________
Printed Name of Member: __________________________________