ALL INFORMATION WILL BE KEPT PRIVATE AND CONFIDENTIAL.

Applicant 1
Full name:
(Last names are held in strict confidence)
Preferred name for name tag (first name or nickname):
Birthday (month/day):

Applicant 2
Full name:
(Last names are held in strict confidence)
Preferred name for name tag (first name or nickname):
Birthday (month/day):

Email
Email is our primary mode of communication to notify members of events and other important information.
Please indicate your preferences.
Email both of us at this primary address:
In addition, email a copy to this address:

Mailing Address
Street:
City: State: Zip:

Phone Numbers
Primary #: Area code Number
Alternate: Area code Number

Your Anniversary: Month Day Year

Referred by, if applicable:

We learned about FGCC through:

Waiver and Participation Agreement
We, the applicants listed above, are aware that our participation in the activities of Florida Gulf Coast Couples, Inc. (FGCC) may involve potential risks of injury, and we are voluntarily participating in such activities with that knowledge. We acknowledge that we will use our own best judgment to avoid injury to ourselves and others. We agree to abide by the rules of public venues at which FGCC activities are held. In consideration for FGCC's membership services, we release FGCC, including its board of directors and officers, activity leaders, event hosts, and other FGCC representatives, from any liability for injuries to our person or property resulting from our participation in FGCC activities. We further agree to hold harmless and indemnify FGCC and said representatives against any claims, liabilities, lawsuits, attorney fees, or costs to which they may be subject due to our acts or omissions in connection with FGCC activities. Our initials below indicate our agreement to the above terms.
Applicant 1 Initials: Applicant 2 Initials:

Photograph Consent
We consent to being photographed at FGCC events for posssible publication in the newsletter and on the website.
YES or NO:

Please note any comments you would like to make:

Your membership will not become official until your check is received.

Please note: Our "thank you" confirmation page is temporarily unavailable. When you hit submit, a page will come up that says "The webpage cannot be found." (Your submission will have been received at this point.) Click on "Go back to the previous page," which will return you here. Scroll to the top, and click any button in the top row to navigate away from this page. We are working to repair this problem and apologize for the inconvenience.