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Member Welcome Form

First Name

Middle Initial

Last Name

Your Birthdate

Please check here if you would like to keep your date of birth private, and we won’t recognize your birthday in public. We still need your date of birth because knowing the ages of our participants is critical for our funding.

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Physical Address (If different from mailing)

Address Line 1

Address Line 2

City

State

Zip Code

Gender

Male

Female

Other

Your Email

I would like to receive the Bugbee Bulletin electronically by email.

I would like to receive the Bugbee Bulletin by mail

Do you live alone?

Are you a veteran?

Disabilities, if any:

Food allergies (diabetic, etc.):

May we use photos of you in our publicity materials? (We will show you first!)

Emergency Contact Information (provide up to 2 contacts):

Name	Relation	Phone