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COURSE REGISTRATION AND MEMBERSHIP FORM Marshfield Branch, Cambridge YWCA Ferry Hill Road Marshfield 02050 781-834-8371 Name: Mailing Address: Telephone #: City and Zip: Email: Class Name: Fee: Playroom? Names and Ages of Children: Fee: Class Name: Fee: Playroom? Names and Ages of Children: Fee: Class Name: Fee: Playroom? Names and Ages of Children: Fee: Membership: check your address label Circle: NEW RENEWING Adult membership is $30.00 Child membership is $ 5.00 Fee: Contribution: $ Credits: $ Total: $ Ethnic Background--Optional Information American Indian Asian Black Black Hispanic White White Hispanic Other I would like to help with: Fundraising Programming Policy Making Building & Grounds FOR OFFICE USE Membership Start Date:_____________ Membership Expiration Date:________________ Card Number:__________ Check/Money Order #:____________ Check/Money Order Date:_______ Amount:________ Staff Initials:______