Form Login Account (optional)

New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish the form. The account you establish is only for this form. When setting up accounts for the form, we ask for an email address. This email address will only be used to provide you with login details and for recovering lost username/password combinations. NO SPAM!

Project 21 Member Sign-Up

Gift or Personal Membership

Fill in the information below to become a Project 21 Member. Make sure you click "Submit" at the bottom of the page.

* Is this Project 21 membership for yourself or a gift for someone else?

I am purchasing this membership for myself

I am purchasing this membership as a gift for someone else

Enter Your Personal Information

* First Name

* Last Name

* Address 1

Address 2

* City

* State

* Postal Code

Home Phone

Cell Phone

* Email Address

Please email me event and volunteer updates

Enter your date of birth (This information is optional if purchasing the membership as a gift for someone else)

Enter Gift Recipient's Personal Information Here

(If applicable)

First Name

Last Name

Recipient’s date of birth

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Cell Phone Number

Email Address

Please email me EVENT AND VOLUNTEER updates

When should we notify the recipient of the gift? (Recipient will be notified of the gift via email or if no email, by USPS)

Write a message for the gift recipient here (No limit character limit)

Payment Information

* How would you like to pay for your Project 21 membership?

Credit card (Complete credit card info below)

Cash/check (Complete this form then call us)

PayPal (Complete this form the click PayPal button at the bottom of this page)

* Enter the TOTAL dollar amount you are authorizing SafeRide America to charge to your credit card. (Enter 00.00 if paying with cash/check or PayPal) The minimum amount is your age or the gift recipients age in dollars. We encourage new members to add an addtional donation to the membership cost. An additional $5 to $10 can really make a difference. The donation is tax-deductable. CLICK HERE to print a receipt for the additional donation.

Name on Card

Credit Card Type

Credit Card Number

CSC Code

Expiration Date (mm/yy)

Billing Zip Code

* Are you donating more than your age?

Yes

No, I will be paying my age exactly.

Did you donate double your age or more?

No

Yes

More

Enter the additional donation dollar amount

Click here to download or to print out a tax-deductable receipt for the addtional donation amount

If donating double your age or more, do you want your name to appear on our "Friends of SafeRide Home Page"?

No, I prefer to remain anonymous

Yes, first and last name only

Yes, first name and last initial

I would like my listing to read "A tribute to...(enter persons name in the box below)"

* Previous SafeRide America Member?

Yes

No

Not Sure

* Are you willing to come out and volunteer at least one night a year?

Yes

No

* How did you hear about us?

* Select the name of the SafeRide America representative that told you about Project 21

Enter any questions or comments here. If redeeming a gift certificate please enter "gift certificate" in this box.

* Indicates Response Required

Gift or Personal Membership

Enter Your Personal Information

Enter Gift Recipient's Personal Information Here (If applicable)

Payment Information

Enter Gift Recipient's Personal Information Here

(If applicable)