Lions Club Membership Application

Personal Details

First Name

Last Name

Middle Initials

Birth Date

Gender

Contact Details

Phone Number

Email Address

Personal background

Occupation

Spouse Name

Contact Information

Street Address

City

State

Zip Code

Club & Sponsor Details

Club name

Member Sponsor

Membership Type *

Are you a:

New member Former member Transfer member

Member number

Previous Club Name

Previous Club Number

Select membership category *

Family Member Student Former or Current Leo Young Adult

Create Your Member Account

Create a password to activate your Basalt Lions Club member account. You’ll be able to log in anytime using your email and this password to manage your membership and stay connected with our community.

Create Password

Confirm Password

Be at least 8 characters long
Include at least one uppercase letter (A–Z)
Include at least one lowercase letter (a–z)
Include at least one number (0–9)
Include at least one special character ( ! @ # $ % ^ & *)
Passwords match

1. PERSONAL DETAILS

Edit

First Name:

Middle Initials:

Gender:

Birth Date:

Email:

Phone Number:

2. CONTACT INFORMATION

Edit

Street:

City:

State:

Full Address:

Occupation:

Spouse Name:

3. CLUB & MEMBERSHIP DETAILS

Edit

Club Name:

Sponsor Name:

Membership Type:

Membership Category:

4. MEMBERSHIP FEE

Total fees $85.00

MEMBERSHIP DISCLOSURE

I accept membership into Lions Club International and that the standards are limited to persons of good moral character and reputation. I recognize the importance of rendering personal service to my community in cooperation with other civic-minded persons. I understand that membership is not valid until approved by the club’s board of directors.

membership disclosure

I have read and agree to the above membership disclosure.