Service Clubs Sign Up Form

Required fields are marked with * below.

*	Club Type:	If Club Type is not on drop down list, select "Other" and fill in box.
*	Club Name:
*	Name:
	Title:
*	Address:
*	City:
*	State/Province:	If State is not on drop down list, select "Other" and fill in box.
*	Zip/Postal Code:
*	Phone (555-555-5555):
	Cell Phone:
*	Email Address:
	Preferred Contact Method:

Mark ALL appropriate boxes:

	Please send me additional information about Harrison's Hope and the Service Club Program.
	Please send me the 20-minute Harrison's Hope Introductory Video for an upcoming organization meeting.
	Please send me a kit which includes all the materials needed to fulfill the program (e.g. brochures, posters, etc.). My club is committing to complete the Harrison's Hope Service Club Program. I understand that the kit is free with the exception of the shipping charges.
	My service club has already completed the program. Please send me the Harrison's Hope "Banner Patch."
	My service club is interested in conducting a Harrison's Hope fund raiser. Please contact me regarding potential opportunities.
	My service club would like to donate $ to Harrison's Hope.