Join the Lifelong Learning Institute in Chesterfield...
The annual membership fee of $150 per person allows individuals to sign up for all of the courses, lectures and planned social events available during their 12 months of membership. Fitness courses will have an additional fee, and select other courses may have an additional fee for materials. Please complete this form and then follow the link on the confirmation page to pay your membership fee by debit or credit card. Checks can be made payable to the Lifelong Learning Institute and mailed to PO Box 1090, Midlothian, VA 23113. Membership is not active until payment has been received. Thank you!
Title
First name: *
Last Name: *
Name you wish to be called: *
Street address: *
City: *
ZIP code: *
Home phone:
Cell phone:
Other phone:
Email address:
Email is the prime way we will contact you if provided.
Birthdate:
MM/DD/YYYY
Be included in the membership directory for members published periodically?
We publish only name, address and phone number.
How did you learn of the Lifelong Learning Institute?
This is helpful in our marketing.
If you were referred by a LLI member, who was it?
Name and, if you know it, their membership number.
Besides taking classes are you interested in...
There are many ways to be involved at LLI
If you might teach a class, please indicate the subject area:
Do you have any special needs?
Name of contact in case of an emergency:
Your relationship with emergency contact:
Sister, spouse, friend, neighbor, etc.
Phone number of contact in case of an emergency:
Physician Name: *
Physician Phone: *
Allergies/Important Medical Information: *
Are you currently a member of LLI? *
To pay my dues, I will *
Complete how-to details in step 2. (There is a $3.50 fee for online credit card processing.)
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