Optimist Club Member Application Name(Required) First Last Were you ever a Junior Optimist Member?(Required) Yes No Are you currently a full-time college student?(Required) Yes No Home Address(Required)Physical Address, not a PO Box Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Cell PhoneHome PhoneEmail(Required) Work PhoneDate of Birth MM slash DD slash YYYY Sponsor(if any) First Last Please note:Individuals who have committed sexual offenses against children may be denied membership and/or have their membership revoked.Signature(Required)Use your mouse on desktop or use your finger on cell or tablet to sign your application.Membership Dues (Select One)(Required) Annual Dues Quarterly Dues Total Credit Card(Required)Card Details Cardholder Name EmailThis field is for validation purposes and should be left unchanged.
