Membership Year

Name *

First

Last *

Last

Email *

Region *

Membership Name *

Membership # *

To better communicate with our SoCal Membership, we will be using a mass mailing system called MailChimp, similar to Constant Contact. Your email address will be added to our mailing list and we will limit the number of emails we send.

Please acknowledge that your email address will be used to communicate with you using this system.

MailChimp Mailing List Communication *

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Your Role *

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