EmailMe Form - Copy of

Name: *

First Last

Please Provide Name of Secondary Family Member who is at Least 18 years of Age, if Purchasing Family Membership.

First Last

Address: *

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

Phone *

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

Email: *

Are You a New or Renewing Member?: *

New

Renewing

Referred By:

Membership Level: *

New Members Receive LPCHS Apparel, Please Select:

How Would You Like to Receive Your Apparel ?

I'll pick up at the Shelter!

Mail me my apparel!

Please Select Date & Time You Wish To Pick-Up:

MM / DD / YYYY HH : MM AM/PM

*Please Note - Memberships purchased over the weekend, will not be available for pick up until the upcoming Monday.