Mailing Address:

    Email Address:

    Home Phone:

    Mobile Phone:

    Work Phone:


    Job Title:



    Birthday (MM/DD):

    Your Optimist Sponsor:

    (please list the Optimist Club Member that referred you to our club) :

    Membership Type:

    Regular Member: a member who attends meetings regularly and is active with club activities.

    Associate member: a who is unable to attend regular meetings but would like to continue to support the club financially and stay informed of activities.

    Select a shirt type and size:

    Each new member receives an Optimist Logo shirt. Please select the shirt type and size you woudl like.

    Comments (optional):