MEMBERSHIP APPLICATION

Preferred Title

First Name

Last Name

Email

Mobile

Gender:

Nationality

Birthdate

Proof Of Age Please upload a clear photo of your proof of age (i.e. passport or driver's license)*

YOUR CONTACT DETAILS

Address

Address 2

City

State/Province

Zip/Postal Code

Country

YOUR PROFESSIONAL DETAILS

Occupation

Company

Industry

Instagram Handle

Other

Linkedin URL

YOUR PHOTO

Please upload a clear photo of yourself Maximum upload size 10MB.

ABOUT YOU

Please include a short bio below. This can include your passions, interests, family, career, etc, to best represent who you are and what you will contribute to our Membership Community.

AGREEMENT

I/WE HEREBY APPLY FOR MEMBERSHIP TO THE CLUB AT CASA CIPRIANI SOUTH STREET

Date

AcknowledgementBy checking this box I/we certify and acknowledge that if the above signature lines are NOT completed and dated that I/we are NOT applying for Club Membership. Alternatively, I/we certify and acknowledge that if the above signatures lines ARE completed and dated that I/we ARE applying for both Club and Wellness Memberships.

By checking this box, you are confirming that you would like to receive any and all communications from the Club Casa Cipriani. You can choose to opt out of emails or unsubscribe at any time by contacting our team at membership@casacipriani.com or simply clicking unsubscribe on the email.