The Clay Club :: Space Studios :: Registration Form

I have read and agree to the Clay Club Policies.

Name: _____________________________________________________________________ Date: _____/_____/_____

Address: ________________________________________________________________________________________

City: __________________________________________________ State: ________________ Zip: ________________

Phone: (Home) _________________________ (Work) _________________________ (Cell) ______________________

Membership: 4 Weeks/$100 13 Week/$276 26 Week/$520 52 Week/$910

Payment: Credit Card Cash Check Payable to Space Studios / Check#_________ Amount $ ________

Credit Card Type: __________________________________________________________ Exp: ____ / ____

Card Number: ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ - ___ ___ ___ ___ V Code: ___ ___ ___

Cardholder’s Name (as it is printed on the card): ____________________________________________________

Office Use Only:

Membership Start Date: _____ /_____ / _____ End Date: _____ /_____ / _____ Date Received: _____ /_____ / _____