Membership & Renewals

Membership

Date*
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*
Emergency Contact Person*
Emergency Contact Phone*
Baja Community*
Please select the community you live in.
Membership Card Mailed to Click On ?
- Click On
Please check this box if you CURRENTLY receive mail at ClickOn and would like your card to be mailed to your box there.
Click On Box Number
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 - 1 year
- Individual - 2 years
- Individual - 3 years
- Individual - 4 years
- Individual - 5 years
- Individual - Lifetime
Type of Membership*
- Individual + Co-Applicant - 1 year
- Individual + Co-Applicant - 2 years
- Individual + Co-Applicant - 3 years
- Individual + Co-Applicant - 4 years
- Individual + Co-Applicant - 5 years
- Individual + Co-Applicant - Lifetime
Would you like a free car decal?*
Those who purchase a membership greater than 1 year are eligible for a free car decal (2 if you have a co-applicant). Please indicate if you would like to receive a free decal.
- Yes
- No
Car Decals (Optional) Quantity
Price:
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. Leave this blank if you do not want a car decal.
How many car decals would you like?
Leave blank or add 0 if you do not want a decal.
Would you like to make an additional donation to Cruz Roja?

Please add in any denomination you like.
Total
$0.00

Membership & Renewals

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