Ambassador Membership Form

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Communication Ambassador

Event Ambassador

Engagement/Fundraising Ambassador

I would like to automatically renew my membership

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First Name *

Last Name *

Email *

Phone *

Best daytime phone number

Address Line 1 *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Country

Secure Payment

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Include a submember in your membership registration

Include a submember

SUBMEMBER {{index+1}}: {{getSubMemberName(index)}}

Choose Existing Contact(s)

Membership Level *

I would like to automatically renew my membership

First Name *

Last Name *

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

Add a submember

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$ Add a donation

Other Amount

{{donationOtherAmountLabel}} *

USD

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{{orderSummary.membershipOrderItem.startDate}} - {{orderSummary.membershipOrderItem.endDate}}

{{orderSummary.membershipsTotal==0?'Free':formatAmount(orderSummary.membershipsTotal)}}

Membership auto-renews monthly for {{ formatAutoRenewAmount(orderSummary.membershipOrderItem.membershipInstallment.cost) }} until {{ orderSummary.membershipOrderItem.membershipInstallment.endDate }}

Membership auto-renews on {{orderSummary.membershipOrderItem.membershipAutoRenew.renewDate}} for {{formatAutoRenewAmount(orderSummary.membershipOrderItem.membershipAutoRenew.cost)}}

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Membership auto-renews monthly for {{ formatAutoRenewAmount(orderSummary.membershipOrderItem.membershipInstallment.cost) }} until {{ orderSummary.membershipOrderItem.membershipInstallment.endDate }}

Membership auto-renews on {{orderSummary.membershipOrderItem.membershipAutoRenew.renewDate}} for {{formatAutoRenewAmount(orderSummary.membershipOrderItem.membershipAutoRenew.cost)}}

{{sm.userName}} (Submember)

{{sm.startDate}} - {{sm.endDate}}

Membership auto-renews monthly for {{ formatAutoRenewAmount(sm.membershipInstallment.cost) }} until {{ sm.membershipInstallment.endDate }}

Membership auto-renews on {{sm.membershipAutoRenew.renewDate}} for {{formatAutoRenewAmount(sm.membershipAutoRenew.cost)}}

Donation

Discount Code

Code:

-{{formatAmount(orderSummary.codeDiscount)}}

Order summary

Subtotal {{formatAmount(orderSummary.subtotal)}}

Discounts -{{formatAmount(orderSummary.discounts)}}

Total {{formatAmount(orderSummary.total)}}

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Card

or enter your card details below

Cardholder First Name *

Cardholder Last Name *

Cardholder Email

Card *

Billing address is the same as mailing address

Address Line 1

Address Line 2

City

State/Province

Zip *

Country

Amount:

{{formatAmount(totalAmount)}} USD

({{formatAmount(amexTotalAmount)}} USD for AMEX cards)

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CASA Wilco Ambassador Program

For questions regarding Ambassador Program, please contact Wendy Prindle wendy.prindle@casawilco.org or 512-658-2748.

2100 Scenic Blvd, Ste 110

Georgetown, TX 78626

www.casawilco.org

Membership level allows for a maximum of {{term.subMemberAllowed}} submembers.

	Contact Name	Membership Level
	{{item.contactName}}	{{item.membershipLevel==null?'-':item.membershipLevel}} {{item.startDate}} - {{item.endDate}}
No contacts.