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First Name

Last Name

E-mail Address

Contact Phone
- -

How would you like to pay?
VISA/Mastercard
Check
Cash (paid at event)
Call me to collect my credit card info

Note: If paying by check, it must be received by Thursday, April 17th. Please make your check payable to Eugene Active 20/30 Club and mail to:

Eugene Active 20/30 Club
P.O. Box 365
Eugene, Oregon 97440

If paying online with your VISA or Mastercard, please enter the card info below:

Expiration Date: (mm/yy)

The best time to contact me is: (you may check multiple boxes)
Morning 8:00-11:59 a.m
Afternoon 12:00-5:59 p.m.
Evening 6:00-9:00 p.m.