Demo Membership Form Become A Member (Credit Card) "*" indicates required fields Surrey Membership or Renewal*$50.00Total Member InformationMembership Type* New Member Renewal Date of Birth* Month Day Year Member is Payee I will be paying for my own membership Name* First Last Email* Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone* I am interested in volunteer opportunities. Newsletter Preference Email Mail Payer InformationName*Important: Details need to match those of the credit card you’ll be paying with. First Last Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Statistical InformationMarital Status* Married Single Widowed Veteran* Yes No Primary Language* English Spanish French Italian German Other Race/Ethnicity* Black/African American Hispanic/Latinx Caucasian/White Asian/Pacific Islander American Indian/Native Alaskan Other Refuse to Answer Disabilities* No Yes Identify Disabilities Living situation* Alone With Spouse With Relative With Friend Number of people living in your household*(including you) 1 2 3 4+ Annual Household Income:Last year you filed taxes?* As an Individual Jointly If you live alone, was your taxable income last year more than $37,470?* Yes No If you file taxes jointly, was your taxable income last year more than $50,730?* Yes No Years living at above address* 0-5 6-10 11-20 More than 20 Employment* Retired Working-Part time or Full time On Disability Unemployed/ Looking for Work I hereby exonerate and hold harmless Surrey its officers, directors. employees and volunteers from any and all illness and injuries (including death) which may occur as a result of, or during, any such activities, trips and/or services in which I participate. I intend to be legally bound hereby. I authorize the leader in charge of the activity, trip and/or service to obtain a physician or hospital care in any emergency, illness or accident. At that time, the Emergency Contact will be notified.Member Signature*Please type your name to sign. DateUse the calendar to pick today’s date MM slash DD slash YYYY Payment Method*PhoneThis field is for validation purposes and should be left unchanged.
