Be a Club Round VIP MEMBER

*VIP Membership good for one year.
*VIP Membership card.
*Events listing mailed to your door.
*Discounted fees at all events.
*“VIP Members Only” functions.
*E-mail notification of all events.
*Eligibility for Clubhouse Committee.

*One free guest pass to bring a friend.

VIP MEMBERSHIP COST IS $25.00
Make check payable to: Lisa A. Breisch, Psy.D.
Mail to: Club Round Clubhouse
7120 Windsor Lake Parkway
Suite 202 Upper Level
Loves Park, IL 61111

Cut, paste, print out and send this form with your membership fee and your membership packet will be mailed to you.

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Club Round: A Clubhouse for Round People
VIP Membership Application
Thank you for wanting to be part of the Club Round Clubhouse family of VIP Members. Let’s get you registered with Club Round!! Please share some information about yourself:

How did you hear about Club Round: A Clubhouse for Round People?

________________________________________________________

Your Name:______________________________________________

Date of Birth:_________________________ Age:________________

Address:_________________________________________________

________________________________________________________

Home Phone:_______________________________________

Cell Phone:_________________________________________

Type of employment:_____________________________

Work Phone Number:_____________________________

Are you interested in networking with other VIP Members?  Yes___   No ___

E-Mail Address:____________________________@________________________

Emergency Contact Person:____________________________

Relationship to you:___________________________________

Their Address:_______________________________________

___________________________________________________

Their Phone:_________________________________________

Circle all that apply. Are you a BBW, BHM, Admirer, Supporter, Female, Male?

Your interests in Club Round: Dances, Support Group, Movement Classes, Nutrition, Kids Events, Teen Events, Adults Only Events, Volunteering at Events, Women Only Events, Men Only Events, Committee,

Other please specifiy:____________________________________________

VIP MEMBERSHIP COST:
Special Reduced Rates!! $25.00 per person (original cost is $100.00).

Anyone else in your household you would like to include in your membership?

To add another individual(s) to your membership, please add $5.00 per person to the membership fee. Specify their name(s) and relationship. The person(s) must reside at the same address as you. They will become VIP Members of Club Round and will be given the same membership benefits.

Total Membership Fees Paid: $____________________

Cash or check only accepted. Made out to Lisa Breisch, Psy.D.

Mail to: Club Round c/o Lisa Breisch, 7120 Windsor Lake Parkway, Suite 202, Loves Park, IL 61111.

Spouse/Significant Other:________________________________

Child/Teen:___________________________________________

Child/Teen/Other:______________________________________

Child/Teen/Other:______________________________________

___________________________________________  __________
Signature                                                                        Date

____________________________________________ __________
Club Round Staff Signature                                              Date

Notes:______________________________________________________

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