EmailMe Form - Mixson Club Membership Application

Name *

First Last

Sponsor *

First Last

Address *

Street Address City State / Province / Region Postal / Zip Code

Contact Number *

### - ### - ####

Birthday *

MM / DD / YYYY

Email Address *

Membership Class & Type

Please choose ONE *

MIXSON RESIDENT

CHARLESTON RESIDENT

MIXSON RESIDENT: Full-time resident of the Mixson Neighborhood

CHARLESTON RESIDENT: Full-time resident of the Charleston Metro Area

Please choose ONE *

FAMILY

DUAL

INDIVIDUAL

FAMILY: Residents of a single household

DUAL : Two individuals living in the same household with no children.

INDIVIDUAL- Single person

Please include photographs of each family member *

You may add multiple files.

Employment History
(last 3 years) *

Why do you want to be a member?
( 5 sentences or more) *

What is your favorite poolside cocktail? *

PAYMENT DETAILS

There is an application charge of $50. This is a non-refundable Membership processing fee. This fee can be paid via cash, check or credit card upon submission of the application.

Signature

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Acknowledgment of Applicant: I have read the acknowledgment of applicant and agree to the terms provided. Please initial below.

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