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Basic Membership &

Community Membership Agreement

Level 1a & 1b  v1 2018

Copyright 2018 All Rights Reserved

Basic Medicinal Mindfulness Membership and Community Membership levels are a way to stay connected with the Medicinal Mindfulness community and to support the mission and programs of Medicinal Mindfulness.

Please choose a membership payment at the bottom of this form:

1a - $10/month or


1a - $99/year


1b - $25/month or


1b - $250/year (community sponsor)

  • MM member/supporter
  • Private Event Invitations based on membership level
  • Members email updates
  • Membership card

Compensation and Billing:  Member agrees to pay monthly payment via credit or debit card at the commencement of this agreement and Medicinal Mindfulness will automatically charge the monthly fee to the card on file every 30 days for one year.  Member will be contacted to confirm renewal after one year term.  Annual memberships will be renewed only after approval from member.

You will receive an invoice for recurring payment through our PayPal Account.  We won’t keep your credit card on file.  

Termination:  Membership can be paused or terminated at anytime and the automatic withdrawal for future payments will be cancelled.   

 

Membership Agreement Acknowledgement
I have read this document and requirements for being a member of Medicinal Mindfulness and agree to comply with these expectations.

 

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
Please Choose a Membership Level
1a - $10/month
1a - $99/year
1b - $25/month
1b - $250/year (Community Sponsor)
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Please Choose a Membership Level
1a - $10/month
1a - $99/year
1b - $25/month
1b - $250/year (Community Sponsor)
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Please Choose a Membership Level
1a - $10/month
1a - $99/year
1b - $25/month
1b - $250/year (Community Sponsor)
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Please Choose a Membership Level
1a - $10/month
1a - $99/year
1b - $25/month
1b - $250/year (Community Sponsor)
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Please Choose a Membership Level
1a - $10/month
1a - $99/year
1b - $25/month
1b - $250/year (Community Sponsor)
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Please Choose a Membership Level
1a - $10/month
1a - $99/year
1b - $25/month
1b - $250/year (Community Sponsor)
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Please Choose a Membership Level
1a - $10/month
1a - $99/year
1b - $25/month
1b - $250/year (Community Sponsor)
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Please Choose a Membership Level
1a - $10/month
1a - $99/year
1b - $25/month
1b - $250/year (Community Sponsor)
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Please Choose a Membership Level
1a - $10/month
1a - $99/year
1b - $25/month
1b - $250/year (Community Sponsor)
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Please Choose a Membership Level
1a - $10/month
1a - $99/year
1b - $25/month
1b - $250/year (Community Sponsor)
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Please Choose a Membership Level
1a - $10/month
1a - $99/year
1b - $25/month
1b - $250/year (Community Sponsor)
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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