James R. Jordan Club Interest Form

Confidentiality: Any confidential information requested is for our records and for the funding our organization receives. The answers you provide will be kept confidential. Your cooperation in providing this information is both appreciated and necessary. Required fields are denoted with asterisks.

Member Information

Child's Name (required)*

First Last

Child's School (required)*

Child's Grade (required)*

Parent/Guardian(s) Information

Parent/Guardian Name (required)*

First Last

Address (required)*

Street Address City State ZIP Code

Preferred Email Address (required)*

Parent/Guardian Mobile Number*

Parent/Guardian Home Number

Parent/Guardian Work Number

Relationship (required)*

Question or comment