Membership Application

Thank you for your interest in Wild Quail!  Here at Wild Quail, our members are our top-priority.  

We are constantly taking steps to ensure that we deliver the highest quality and customer service to each and every one of our members.  Below is the application for membership.  

Membership types can be found under the "Membership" tab above under the "Membership Type" option in the drop down box.  Upon completion of the application, we will contact you to receive your billing information.  If you have any additional questions, feel free to contact Charley Anderson, charley@wildquail.net,  or call 302-697-4665 

**Please read this document before completing the application.  Typing your full name into the "Agreed to" field certifies that you have read, understand, and agree to the conditions of membership provided in this document:

Application for Membership & Statement of Agreement

First Name*:
Last Name*:
Email*:
Company Name*:
Phone*:
Address*:
City*:
State/Province*:
ZIP/Postal Code*:
Question/
Comments:
Birthdate * :
SPOUSE INFORMATION (all fields required if married) :
Spouse Name * :
Spouse Birthdate :
Spouse Email :
Spouse Company Name :
Dependent Information (Under 21)
Dependent 1 Name :
Dependent 1 Birthdate :
Charging Privileges? (Check if yes) :
Dependent 2 Name :
Dependent 2 Birthdate :
Charging Privileges?
Dependent 3 Name :
Dependent 3 Birthdate :
Charging Privileges?
Type of Membership :
Agreed to (*See text above): * :
Please select your preferred form of payment. :
How did you hear about us? Did anyone assist you in your decision to join? *