PROTECT LIFE PARTNER APPLICATION

Signer's Info

Name*

Address*

Email*

Phone Number*

Yes, it's okay to send me text messages including order confirmations, updates, event reminders, and event information. Message frequency varies. Message and data rates may apply. Reply HELP for help, STOP to cancel. View our terms of service & privacy policy.

Your Officer Position (Signer Must be An Officer)*

Secondary Contact's Info

Secondary Contact Name (another officer we can reach)*

Secondary Contact's Email*

Secondary Contact's Phone Number*

Secondary Contact's Officer Position*

Group Info

Multiple Choice*

Current Name of the Group You Represent (if applicable)

NEW Protect Life Name You Desire to Use if Approved (if applicable)

Personalized Promotional Packet Details

Please Check the Items You'd Like Included in Your Promotional Packet:*

NONE: We do not need a promotional packet.
Personalized Banner WITH Protect Life logo
Personalized Banner WITHOUT Protect Life logo
Personalized handouts explaining your group
Stickers
Pins
Dropcards
Tablecloth (black fabric, not personalized)
A Protect Life Constitution (often required by your school)
A "to do" list on how to change your group's name

Please provide us with information on what materials and support you need in your potential transition:*

What colors would you like on your banner? Please be as specific as possible, including HTML color codes if you have them:

What would you like on your banner? Any specific text? Your mission? Facebook/Twitter/Instagram? Please be specific:

Please provide us with a name & mailing address to send the promotional package to:*

Signature

For complete terms of this agreement, see Section XI of Protect Life Michigan's Bylaws.

By signing below, I confirm that I have read, understand, and agree to comply with Protect Life Michigan's Bylaws.

Written Signature (type name):*

This page is secured with 256 bit encryption

Event Registration Software by RegFox