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Club 21 Membership/Afiliación de Club 21

2024 Membership is $60. All memberships are valid through December 31, 2024.

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 each January
*la afiliación TIENE QUE ser renovada cada enero 

Ethnicity: Optional: This information is collected for Grant Writing/Reporting purposes
Additional Details/Detalles adicionales

My response indicated by checking a box below indicates that I permit and authorize Club 21 Learning and Resource Center in Pasadena, California, and employees, agents, and personnel who are acting on behalf of Club 21, to use the following for purposes related to the overall mission of the organization, including publicity, marketing and promotion of Club 21 without compensation to me. I understand the above may be subject to reasonable modification or editing and may be reproduced and distributed by means of various media, including but not limited to publications, video or digital presentations, television broadcasts/rebroadcasts or radio transmissions/retransmissions, news releases, mail outs, billboards or signs, brochures or Web sites. I waive any right to inspect or approve the finished product, or any material in which Club 21 may eventually use my image, video, words, artwork, and information or other items indicated above. I understand that while Club 21 will endeavor to use the above in accordance with standards of good judgment, Club 21 cannot warrant or guarantee that any further dissemination of the above will be subject to Club 21 supervision or control. Accordingly, I release Club 21 from any and all liability related to dissemination of my video, image, words, information, and participation as a member and other items indicated above. This consent and release shall be binding upon my heirs, successors, assigns and legal representations. I have read this document and fully understand its contents.

Club 21 Membership/Afiliación de Club 21

If you are using Self Determination Program funds, please fill out the information below: 

Credit Card Information
Your total payment will be
Your credit balance will cover
Your credit card will be charged
Your bank account will be charged