Breakfast Club: Application

Member Application Form

Membership Application

Business Information

Business Name*

Years in Operation*

Website:

Facebook:

Instagram:

Address:*

City:*

Postal Code:*

Business Owner Name:*

Business Owner Email:*

Attendee Information

Full Name:*

Birthday:

Email (We Will Reply to This Email):*

Phone Number (Numbers Only):*

Alternate's Full Name:

Alternate's Birthdate:

Alternate's Email:

Alternate's Phone Number (Numbers Only):

70% of my business activities are:*

30% of my business activities are:*

Attendence Declaration:*

As a new member of the Breakfast Club of Regina, we will follow the constitution of the Breakfast Club of Regina Inc. and maintain a 67% attendance record per year.

Payment Declaration:*

We will pay the first six (6) months of fees upon approval of our membership.

Member Sponsor Information

Sponsor's Name:*

Don't fill this field!