2021 Baseline Application
Last Name *
First Name *
Assembly: *
I am applying as a/an: *
Email *
Physical Address *
City *
Zip Code (9 Digits) *
Mailing Address if different than physical address
Zip Code (9 Digits)
Home Phone number
Cell Phone number
Work Phone number
Place of Birth *
Date of Birth *
Place of Birth *
Marital Status: *
Name of Spouse (if applicable)
I am a Member of good standing in the Grand Lodge of
I am a member of the following Subordinate Lodges : (List all lodges and lodge numbers)
I am a Majority Member of Rainbow Assembly: Assembly name and number
I am a parent, legal guardian or grandparent of an Active or Majority Rainbow member named:
I am a Non Affiliated Wife or a Master Mason: Name lodge and lodge number
For what reason do you wish to become a Certified Chaperone?
What qualities would you bring to the position?
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