• (mm/dd/yyyy)
  • Emergency contact information

  • Dues and Membership Classification

    Please mark the appropriate membership classification. Dues are due and payable April 15 and are delinquent May 31. If you plan to change your membership classification, please submit your request in writing to Vice President Membership. You may email your request to vpmembership@alvisalia.org or mail to P.O. Box 4108, Visalia, Ca. 93278-1408
  • Photo and Name/Donor Release

    Please check your response below. Assistance League Visalia has my permission to include my name as a member of and/or donor to Assistance League in its printed materials such as chapter newsletters, event invitations or programs, press releases, etc. Assistance League of Visalia also has my permission to use any photographs of me taken in connections with Assistance League activities in its printed materials or on the website.
  • Insurance

    I understand that I am required to provide my own health and accident insurance. Assistance League of Visalia is not responsible for any medical or legal expenses that may result from any injury or illness that I may sustain while participating in Assistance League activities. I also agree that I shall maintain adequate personal automobile insurance while using my own vehicle for Assistance League of Visalia business and shall not hold Assistance League liable for any claims that may result from accidents occurring while I am using my own vehicle for Assistance League business.
    BACKGROUND INFORMATION Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? If yes, state nature of the crime(s), when and where convicted and disposition of the case. (Convictions for marijuana-related offenses that are more than two years old need not be listed.) Note: No person will be denied membership solely on the grounds of conviction of a criminal offense. The nature of the offense, date of the offense, the surrounding circumstances and the relevance of the offense to the activities of the chapter may, however, be considered.)
  • Please submit this form and then mail your check for your dues payment to Assistance League of Visalia, P.O. Box 4108, Visalia, CA 93278-4108
  • Date Format: MM slash DD slash YYYY

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