Club 21 Membership

Club 21 Membership/Afiliación de Club 21

Pay your membership today: $15.

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 total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

Ways To Give

- Membership -