YWCA Cortland · Annual Membership Info and Payment Form

As a member of YWCA Cortland, you join our efforts to eliminate racism, empower women, and promote peace, justice, freedom, and dignity for all.

You add your voice to a diverse and powerful sisterhood of 25 million women in 120 countries worldwide.

Your annual membership supports community programs and advocacy efforts to further our mission–a mission that we can't accomplish without you!

Contact Information

If you are renewing your membership, you may have already provided us with the following details. However, completing it again will ensure we have your current contact information and membership details, allowing us to provide you with the best customer service possible.

Name *

First Name

Last Name

Date of Birth *

(mm/dd/yyyy)

Organization/Employer

Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Address Type *

Phone Number #1 *

Provide the phone number at which you prefer us to contact you. You can provide up to two additional phone numbers at the bottom of the page.

Phone Number #1 Type *

Email Address #1 *

Provide the email address at which you prefer us to contact you. You can provide up to two additional email addresses at the bottom of the page.

Verify Email *

Email Address #1 Type *

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Click here to subscribe to our monthly email newsletter and ensure you receive other emails about all the events, classes, and programs happening at YWCA Cortland!

Emergency Contact Information

Please provide information for your preferred contact so we can better assist you in an emergency.

Name *

First Name

Last Name

Relationship *

Phone Number *

Membership Options

We offer “Supportive Membership” for mission-passionate members who wish to support the programs of the YWCA at an increased amount per year. Enrolling in this membership is a statement of your support of the mission of YWCA Cortland to eliminate racism, empower women, and promote peace, justice, freedom, and dignity for all.

If you would like to pay for a Family or Student membership, please do so at the YWCA at 14 Clayton Ave., Cortland, NY 13045.

$40 - Individual (18-59)

$35 - Senior (60+)

$75 - Supporting (any age)

Demographic Information

Providing the following information is voluntary. Failure to complete it will not affect your membership, nor is the information used for employment purposes. However, we would appreciate your cooperation in providing this information, enabling us to serve you and our other members better.

Gender

Racial / Ethnic Background

Select all that apply.

Asian descent (including Central, East, South, and Southeast Asia)

Black / African descent (having origins in Sub-Saharan Africa)

Hispanic / Latino / Latinx (e.g., identify as Hispanic or Latino with ties to Latin America; can be any race)

Indigenous (e.g., Alaskan Native, Aboriginal Australian, First Nations, Native American, Native Hawaiian, Samoan)

Middle Eastern / North African descent (including the Middle East, North Africa, and the Arab World)

White / European descent

Two or more races / ethnicities

Other

Other Racial / Ethnic Background

Please enter your response if you selected "Other" above.

Total Family Income

Total Number in Household

Volunteer Interests

Select all that apply.

Boards

Committees and Workgroups

Events

Fundraising

Programming

Special Needs

Do you have any condition(s) which require special accommodations?

If yes, please specify in the box below.

Children Under the Age of 12

If you have children 12 years of age and younger participating in our programs, please provide their names, birthdates, and genders below.

Child #1 Name

First Name

Last Name

Child #1 Date of Birth

(mm/dd/yyyy)

Child #1 Gender

Child #2 Name

First Name

Last Name

Child #2 Date of Birth

(mm/dd/yyyy)

Child #2 Gender

Child #3 Name

First Name

Last Name

Child #3 Date of Birth

(mm/dd/yyyy)

Child #3 Gender

Child #4 Name

First Name

Last Name

Child #4 Date of Birth

(mm/dd/yyyy)

Child #4 Gender

Child #5 Name

First Name

Last Name

Child #5 Date of Birth

(mm/dd/yyyy)

Child #5 Gender

Additional Phone and Email Contact Information

Phone Number #2

Optional

Phone Number #2 Type

Email Address #2

Optional

Verify Email

Email Address #2 Type

Phone Number #3

Optional

Phone Number #3 Type

Email Address #3

Optional

Verify Email

Email Address #3 Type