Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Contact Phone # *

(###)

###

####

Do you want to be contacted regarding volunteer opportunities? *

Yes

No

Check all areas of interest for which you are willing to volunteer: *

Ag in the classroom

Annual fundraiser

Education (school ag days)

Host member meeting

Food safety

Host recruitment luncheon

Land/water use

Legislation

Newsletter

PR/Advertising

School garden grants

Strawberry festival

Student scholarships

Website

Membership Type *

Please select a membership type:

General Membership ($50)

Corporate/Non-profit donor member ($100) (includes membership for one person who represents the organization)

Student Membership (25)

American Agri-Women ($30) (national coalition of farm, ranch and agribusiness women and organizations)

New Member or Renewal *

Renewal

New Member