Lancaster Shag Club Membership Application

Enter the date of application:

-- mm/dd/yy

Choose one of the following options:

New Member
Renewal

Please provide the following contact information:

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail
URL

Enter your birth date:

Enter your anniversary date (if applicable):

Please provide the following contact information for your spouse (if applicable):

First Name
Last Name
Work Phone
E-mail

Enter your spouse's birth date:

Please select any of the following committees on which you would be willing to serve:

Social Committee          Membership Committee      Door Prize Committee      Ways and Means Committee
DJ Selection Committee