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COVID-19 Opt-In

Once again, we are being ordered to shut down operations, and we need your help!  Please fill out the form below in order to keep supporting Mesa Rim.  You can choose to continue paying your monthly dues, or you can enter an alternate amount. All revenue will go towards paying essential bills and staff health insurance benefits during the closure.  Thank you for you continued support and understanding!

First Member's Name

First Name*

Middle Name

Last Name*

Phone*
First Member's Date of Birth*
First Member's Information
In what way would you like to support Mesa Rim?*
Continue my current membership dues
Select an alternate monthly amount (Enter in box below)

If you selected "Alternate Amount," please enter that amount here
First Member's Signature*
Second Member's Name

First Name*

Middle Name

Last Name*
Second Member's Date of Birth*
Second Member's Information
In what way would you like to support Mesa Rim?*
Continue my current membership dues
Select an alternate monthly amount (Enter in box below)

If you selected "Alternate Amount," please enter that amount here
Third Member's Name

First Name*

Middle Name

Last Name*
Third Member's Date of Birth*
Third Member's Information
In what way would you like to support Mesa Rim?*
Continue my current membership dues
Select an alternate monthly amount (Enter in box below)

If you selected "Alternate Amount," please enter that amount here
Fourth Member's Name

First Name*

Middle Name

Last Name*
Fourth Member's Date of Birth*
Fourth Member's Information
In what way would you like to support Mesa Rim?*
Continue my current membership dues
Select an alternate monthly amount (Enter in box below)

If you selected "Alternate Amount," please enter that amount here
Fifth Member's Name

First Name*

Middle Name

Last Name*
Fifth Member's Date of Birth*
Fifth Member's Information
In what way would you like to support Mesa Rim?*
Continue my current membership dues
Select an alternate monthly amount (Enter in box below)

If you selected "Alternate Amount," please enter that amount here
Sixth Member's Name

First Name*

Middle Name

Last Name*
Sixth Member's Date of Birth*
Sixth Member's Information
In what way would you like to support Mesa Rim?*
Continue my current membership dues
Select an alternate monthly amount (Enter in box below)

If you selected "Alternate Amount," please enter that amount here
Seventh Member's Name

First Name*

Middle Name

Last Name*
Seventh Member's Date of Birth*
Seventh Member's Information
In what way would you like to support Mesa Rim?*
Continue my current membership dues
Select an alternate monthly amount (Enter in box below)

If you selected "Alternate Amount," please enter that amount here
Eighth Member's Name

First Name*

Middle Name

Last Name*
Eighth Member's Date of Birth*
Eighth Member's Information
In what way would you like to support Mesa Rim?*
Continue my current membership dues
Select an alternate monthly amount (Enter in box below)

If you selected "Alternate Amount," please enter that amount here
Ninth Member's Name

First Name*

Middle Name

Last Name*
Ninth Member's Date of Birth*
Ninth Member's Information
In what way would you like to support Mesa Rim?*
Continue my current membership dues
Select an alternate monthly amount (Enter in box below)

If you selected "Alternate Amount," please enter that amount here
Tenth Member's Name

First Name*

Middle Name

Last Name*
Tenth Member's Date of Birth*
Tenth Member's Information
In what way would you like to support Mesa Rim?*
Continue my current membership dues
Select an alternate monthly amount (Enter in box below)

If you selected "Alternate Amount," please enter that amount here
Parent or Guardian's Email Address

Email
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
In what way would you like to support Mesa Rim?*
Continue my current membership dues
Select an alternate monthly amount (Enter in box below)

If you selected "Alternate Amount," please enter that amount here
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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