membership form
DESCRIPTION
Membership FormTRANSCRIPT
Name_________________________________________
(Maiden name if applicable) ______________________
Address_______________________________________
City__________________________________________
State_____________________ Zip_________________
Phone: (Home)________________(Cell)_____________
Birthdate_______________________________________
E-Mail________________________________________
Married? If “Yes,” please complete the following:
Spouse’s name______________________________
Spouse’s birth date_______________________
Anniversary date____________________________
Children’s names and birth dates*__________________
__________________________________________
__________________________________________
Other family information?* _______________________
__________________________________________
__________________________________________
Present employment and position*_________________
_____________________________________________
Are you presently involved with the YMCA … General Member, Program Volunteer, Policy Volunteer, Part Time Staff, or Professional Staff? _____________________________________________________
Please tell us a little more about what you are doing … hobbies, special interests, special honors and/or awards, academic and/or sports accomplishments, etc. * _______________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
If you know how to contact any other individuals who were BRLS leaders, please include that information … we don’t want to leave anyone out!
If needed, please add another page and continue.
BRLS DATA
Number and years attended BRLS: No_____ Years__________________
Were you ever a:_____Counselor_____Head Counselor_____Honor Leader_____Part Time Staff_____Full Time Staff
_____Current Leader (leader, counselor, honor) Favorite
class:____________________ Favorite memory:*________________
__________________________________________________________________________________________________________________________________________________________________________________________
Most valuable personal experience:*____________________________________________________________________________________________________________________________
MEMBERSHIP INFORMATION
Date Item Sent/Item_____________________________ Paid (circle one ) YES NO
Item Sent_______
Please fill out the Membership Information Form on the other side and choose your Alumni Association Membership Level below: Name____________________________________
______ $10– Basic Informational Membership. Member receives news letter, e-mail, Face Book updates about the AA and the reunions.
______ $25 – Participating Member. Member receives newsletter, access to the database, updates on the AA and reunions. Also included is a picture/Vespers CD of that current year.
_______$10- Each additional Family Member _______$100-Benefactors Club _______$-Extra Donation _______$-Scholarship Donation (each year at BRLS we give one of the leaders;
through an application process, a $1,000 scholarship…the monies go directly to their university for their college education)
You may also purchase Alumni Shirts: _______$20- “7 Star Leader” Award: Collar Shirt.
_______$12- T-Shirt Circle shirt sizes desired: S M L XL
Please send this form and your check made out to BRLS Alumni Association to:
Robert Rosenstein2901 North Duke StreetDurham, NC 27704 TOTAL:____________CK#_______Cash_____ Paypal______________
Questions: Contact Stephanie Torrens, Alumni Association Chair: [email protected]
The purpose of the BRLS Alumni Association is to develop an extended fellowship of former leaders and staff, and
support and enhance Blue Ridge Leaders’ School.