Name *

First Name

Last Name

Name #2

(please include if registering as a couple)

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Phone #2

(for partner, if registering as a couple)

(###)

###

####

What are your preferred ways to communicate?

(member #1)

Email

Phone

Text

What are your preferred ways to communicate?

(member #2, if joining as a couple)

Email

Phone

Text

Past or current member of a community Grange elsewhere?

Yes

No