1. Junior Optimists Farmington – Farmington Hills, MI 2018-2019 (Membership Fee is $15 per year per student)
  2. Student Name(*)
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  3. Student Address(*)
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  4. Additional Address
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  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(*)
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  9. Student Age(*)
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  10. Student Phone Number
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  11. Student T-Shirt Size(*)
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  12. Student Grade Level(*)
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  13. Student School Name(*)
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  14. Club Level(*)
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  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(*)
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  18. 0.00 USD
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