Affiliate Member – Trillium Miata Club

Please fill in the form below with the co-pilot’s contact information, as they are the affiliate (free) member. This membership type must be tied to a full club member (please indicate the full member in the companion field) and will only grant access to certain areas of the website.

Price:

Free

First Name:* First Name Required

Last Name:* Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Associated Full Member Name (This Will Be Checked): Associated Full Member Name (This Will Be Checked) is not valid

Mobile Phone:* Mobile Phone is Required

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

I have read and agree to the terms of the Hold Harmless Agreement and Code of Conduct*

No val Please fix the errors above