New Student Member Account

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Member Information

Member Name *

First

Last

Phone *

Email *

Please provide school issues e-mail address.

School Name *

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Date of Birth *

Gender *MaleFemalePrefer not to answer

Number of Freshwater Tanks

How many Freshwater Aquariums do you currently have and/or maintain?

Please list special interests if any

Share your special interests with us. Example, fish breeding, keeping seahorses, planted tanks, etc.

Number of Saltwater Tanks

How many Marine Aquariums do you currently have and/or maintain?

How did you find out about The Brooklyn Aquarium Society?

Please tell us how you first heard of us.

Waiver and Term Selection

Liability Waiver *

• I release The Brooklyn Aquarium Society and its board members of all and any liability and responsibility.

Brooklyn Tanks Term

Membership Term - 1 YearStudent Member - 1 Year - $15.00

Student membership is only available on annual basis.

Total Amount

$0.00

Choose your payment method. *

PayPal CheckoutCredit Card

Card Number

Expiration Date

Security Code

Card Holder Name

You can pay via PayPal or use your credit card.

Total

$0.00

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