2021-2022 Provisional Membership Application

Name*
First Middle Last
Birthday*
MM slash DD slash YYYY
How many years have you lived in Rankin County?*

Eligibility - one year minimum
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone - Cellular*
Phone - Work
Email*
Enter Email Confirm Email
Place of Employment
Occupation/Title
Children
1. Name
First Last
Age
School
Grade
2. Name
First Last
Age
School
Grade
3. Name
First Last
Age
School
Grade
4. Name
First Last
Age
School
Grade
Emergency Contact Name*
First Last
Emergency Contact Relationship
Emergency Contact Phone*
COMMUNITY INVOLVEMENT/VOLUNTEER EXPERIENCE*
Please list information below regarding your current or previous involvement in community/volunteer programs that you have participated in (include organization names, events, dates).
JARC Relevance*
Please explain briefly what would make you a good addition to JARC.
1. Reference Name*
First Last
Reference Email*
Reference Phone*
2. Reference Name*
First Last
Reference Email*
Reference Phone*
JUNIOR AUXILIARY SPONSORSHIP
Do you have a sponsor?*
If Yes, JARC Member Name
Chapter
Level
Sponsor Email
Sponsor Phone
Have you ever applied for membership to JARC?
Consent*
I agree to the privacy policy.
By clicking here, I verify that all of the information I have provided is true and correct. I understand that at any time, Junior Auxiliary of Rankin County can rescind any rights or privileges to an applicant.

JUNIOR AUXILIARY SPONSORSHIP