First Name:
Middle Name:
Last Name:
Date of Birth:
City of Birth:
Gender:____________ Shoe size:_____________ Favorite Number:_______
Favorite Kenneth Colley movie:__________________________
Who's better looking, Brad Pitt or Kenneth Colley?:_________________________
How often do you shower?______________________
Credit Card Number (optional):
Reason for Joining Club:
What You Will Do To Help Achieve or Mission (3 to 5 sentences):
