Club 21 Membership

Club 21 Membership/Afiliación de Club 21

Pay your membership today: $60.

ATTENTION: After you submit this form, you will be redirected to another page to request your Member Portal Account. Please fill out BOTH FORMS.

ATENCION: Después de rellenar este formulario, se redirectará a una página para pedir su cuenta al portal para miembros. Por favor rellene AMBOS FORMULARIOS.
*all membership MUST be renewed January 2021
*la afiliación TIENE QUE ser renovada cada enero

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First Name/Nombre de pila (Required)

Last Name/Apellido (Required)

Spouse's Name/Nombre de esposo(a)

Address (Line 1)/Dirección (línea 1) (Required)

Address (Line 2)/Dirección (línea 2)

City/Ciudad (Required)

State/Estado (Required)

Zip Code/Código postal (Required)

Phone/Número de teléfono (Required)

E-mail Address/Dirección de e-mail (Required)

Child Name/Nombre de niño (Required)

Child Birthdate/Cumpleaños de niño (Required)

Child Grade/Grado de niño (Required)

School District/Distrito escolar (Required)

List Siblings Name & Birthdates/Liste los nombres y cumpleaños de los hermanos del niño con el síndrome de Down (Required)

Regional Center/Centro regional (Required)

Preferred Language Spoken at Home/Lenguaje preferido (Required)

Ethnicity: Optional: This information is collected for Grant Writing/Reporting purposes

Black or African American
White
Hispanic/Latino/Latinx
Asian
Pacific Islander
Multi-Race

Additional Details/Detalles adicionales

Questions & Comments/Preguntas y comentarios

Club 21 Membership/Afiliación de Club 21

2021 Membership $60

Credit Card Information

Cardholder Name (Required)

Credit Card # (Required)

Visa MasterCard American Express Discover

Expiration Date (Required)

Security Code (Required)

Visa®, MasterCard® & Discover® cardholders
Your security code is the 3-digit code at the end of the signature field on your card's back.

American Express® cardholders
Your security code is the 4-digit code located above the actual credit card number on your card's front.

Billing Zip Code (Required)

Your payment will be

Ways To Give

- Membership -