Junior Optimists Farmington – Farmington Hills, MI 2023-2024 (Membership Fee is $20 per year per student)

Student Name(*)

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Student Address(*)

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Additional Address

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Student City(*)

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Student Zip Code(*)

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Student Birth Date(*)

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Student Age(*)

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Student Phone Number

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Student T-Shirt Size(*)

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Student Grade Level(*)

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Student School Name(*)

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Club Level(*)

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Middle School Age

High School Age

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Parent/Guardian Name(*)

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By checking this box, I, the parent/guardian grant the Optimist Club/International my permission to use a photo/video of my son/daughter for their public relations purposes. Optimist Club/International may use the photo/video in any publication (electronic/print) they see fit.(*)

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Parent/Guardian Daytime Phone Number(*)

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Parent/Guardian Email Address(*)

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Farmington/Farmington Hills Optimist Club
P.O. Box 2203
Farmington Hills, MI 48333