Learning Society Membership

Membership year is July 1 – June 30

Membership Dues (please check one)*

Member - $1,000 ($750 tax deductible) VIP Membership - $5,000 ($4,500 tax deductible)

*Membership is for two individuals

I am*

A new member Renewing my season membership A returning member (not a member this past season)

Title*

Name*

First Name

Last Name

What is your affiliation with Queens?*

Spouse/Additional Member (if applicable)

Title

Name

First Name

Last Name

Preferred Mailing Address:*

Work Home

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Preferred Phone:*

Home Cell Work

Phone*

Email*

Second Email

Title

Company Name

Payment Option*

I will send a check for the full amount I will pay by credit card for the full amount I will pay the non-tax-deductible portion and the additional will come through a Foundation

Once all fields above are complete, please press submit to be directed to the next step of the registration process.