BIRMINGHAM SWING DANCERS MEMBERSHIP Information Membership is $20 per person per year
Name:		Birthday: Mo.__________ Day_ ______					Circle One: Male Female
e-MAIL:	Phone:					Cell:
Current Address:
City:	State:			ZIP Code:
Emergency Contact
Name of a Relative Not Residing With You:
Address:					Phone:
City/State:		ZIP Code:
Relationship:
Spouse Information if joint membership
Name:						Circle One: Male Female
Birthday: Mo.__________ Day__________	Phone:					Cell:
Signatures
Payment Enclosed: Personal Check Cashier’s Check Money Order (Circle one. Do not send cash thru mail)
Signature of applicant:			Date:
Signature of spouse (Joint Membership Only):			Date:
Mail application with check to: Birmingham Swing Dancers, 621 3^rd Terrace, Pleasant Grove, Alabama 35127
If you would like to make a donation to the Birmingham Swing Dancers, please mail check to address above.