Online Membership Payment Form 2017 Membership Payment Form Please complete all required fields and submit this form to pay online by credit card or PayPal. Please note, a 3% convenience fee is added to membership rates for using this payment method. Member Name* First Last Name of primary adult (over 18) member.Other adult member(s) Name / names of other adult member(s). If more than one, use the plus button on the right.Child member(s)Child's full nameChild's D.O.B. ( ex., 01/11/2011 ) Names of additional member(s) under the age of 18. If more than one, use the plus button on the right.Main Phone Number*Please enter the phone number at which is best to reach you.Secondary Phone NumberPlease enter a secondary phone number (ex., work or mobile).Member Email* Primary email address of member.Member's Address* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Full address of primary member.Membership Types: Includes a 3% convenience fee for this payment type. Bonded Member - $823.00 Family on Bond Payment Plan - $973.00 First time Family - $720.00 Single non-bonded - $494.00 (MUST BE 18 YRS OR OLDER) Single Senior - $442.00 (MUST BE 62 YRS OR OLDER) Caregiver - $195.00 Please choose one or more membership types.Bonded Member - $824.00 Price: $824.00 Family on Bond Payment Plan - $973.00 Price: $973.00 First time Family - $720.00 Price: $720.00 Single - $489.00 (MUST BE 18 YRS OR OLDER) Price: $489.00 Single Senior - $439.00 (MUST BE 62 YRS OR OLDER) Price: $439.00 Caregiver - $195.00 Price: $195.00 Emergency Contact* First Last Please enter an emergency contact name.Main Emergency Contact Phone*Enter the phone number at which we can most easily reach your emergency contact.Secondary emergency contact numberIf available, please enter an additional phone number at which we can most easily reach your emergency contact.Total $0.00 This iframe contains the logic required to handle Ajax powered Gravity Forms.