Robins Pacers Membership Form

Please fill out this form and click on the "Submit to Robins Pacers" button below. Use the TAB key or mouse to move from one field to the next. (Pressing ENTER within a field will cause the form to be submitted prematurely!)
Membership is FREE!!



Fields marked with an asterisk (*) are REQUIRED. The form will be rejected if all REQUIRED fields are not filled in, including the consent/non-consent statement at the bottom.

Date:
*First Name:
*Last Name:
*Gender: Male   Female
*Street Address:
*City: *State: *Zip:
*Home Phone:
Business Phone:
*E-Mail Address:


If you'd like to register other family members, please enter their information below (leave "Last Name" blank if same as yours):

First Name Last Name Gender Adult/Child
Male   Female Adult   Child
Male   Female Adult   Child
Male   Female Adult   Child
Male   Female Adult   Child
Male   Female Adult   Child


*I consent to having my address, email address, and home phone number printed in the club newsletter or directory distributed to club members.

Yes
No