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  1. Junior Optimists Farmington – Farmington Hills, MI 2017-2018 (Membership Fee is $15 per year per student)
  2. Student Name(*)
    Please type in student's first name
  3. Student Address(*)
    Please enter student's address
  4. Additional Address
    Please enter additional address information
  5. Student City(*)
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  6. Student State(*)
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  7. Student Zip Code(*)
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  8. Student Birth Date(*)
    / / Please select the student's birth date
  9. Student Age(*)
    Please select student's age
  10. Student Phone Number
    Please input student phone number (123-456-7890)
  11. Student School Name(*)
    Please enter student's school name
  12. Student T-Shirt Size(*)
    Please select Student's T-Shirt Size
  13. Student Grade Level(*)
    Please select the student's grade level
  14. Club Level(*)
    Please select the student's club level
  15. Parent/Guardian Name(*)
    Please enter parent/guardian first name
  16. Parent/Guardian Daytime Phone Number(*)
    Please enter parent/guardian daytime phone number (123-456-7890)
  17. Parent/Guardian Email Address(*)
    Please enter parent/guardian email address
  18. 0.00 USD
  19. Submit and Pay with PayPal, Credit Card, or Debit Card