Personal Information

• Full Name:
• Email Address:
• Phone Number:
• Date of Birth:
• Gender:

• Male
• Female
• Non-binary
• Prefer not to say
• Other: _________________________

Contact Information

• Street Address:
• City:
• State/Province:
• Postal Code:
• Country:

Membership Details

• Membership Type:

• Individual
• Family (Please list additional family members below)
• Student (Valid student ID required)

Emergency Contact

• Full Name:
• Relationship:
• Phone Number:

Terms and Conditions

I agree to abide by the rules and regulations of the Astronomy Club. I understand that participation in club activities may involve inherent risks, and I assume all responsibility for my safety.

Signature: _________________________

Date: _________________________

For Club Use Only

• Registration Date: _________________________
• Membership ID: _________________________
• Payment Received: _________________________