Cruz Roja Primo Tapia Membership Form

Date*
Date Format: MM slash DD slash YYYY
Please select one*
Please select the corresponding choice if you are renewing or becoming a new member.
- Renewal
- New
Name*
First Last
Email*
Phone Number*
Do you want to add a co-applicant?*
Please select this option if you want to add a co-applicant, and fill out the corresponding information.
- Yes
- No
Co-Applicant's Name*
First Last
Co-Applicant's Phone Number*
Co-Applicant's Email*
Baja Community*
Please select the community you live in.
Membership Card Mailed to Click On ?
- Click On
Please check this box if you would like your card to be mailed to Click On.
Mailing Address*
This address will be used to mail your Membership Card.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type of Membership*
- Individual Yearly
- Individual Lifetime
How many years of membership would you like?*
Car Decals
Price: $5.00
Car decals are a great way to let emergency services know you are a member of Cruz Roja should you be in a car accident and cannot speak on your own.
How many car decals would you like?
Would you like to make an additional donation to Cruz Roja?

Please add in any denomination you like.
Total
$0.00

Membership & Renewals