Membership Application Form

Central Coast Singles Membership Form

To apply for membership please complete all questions. You will be asked to submit a picture for identification.
Name *

First Name Last Name
Nickname
Do you have a preferred name?

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail *

Confirmation Email yourname@emailsite.com
Home Number
Cellular Number (Primary #) *
Is text okay? *
Work Number
Facebook/POF
Please provide your social nickname or URL
Gender *
Age *
Memberships available (select below):

Free Membership

Available functions 1 or 2 per month, notification of other functions with option to pay per functions not included with free membership. Matching NOT available. Does not include cost of events or surcharges.

Possible events may include:

Dancing / Public Mingles / Coffee Mixers

Holidays & Fireworks / SLO Farmer’s Market

Memberships are paid quarterly or annually

Full Membership ($36/Q, $125/yr)

Includes free benefits listed above plus additional events up to 4 per month, notification of other functions with option to pay per function not included with Full membership. Does not include cost of events or surcharges. Matching NOT available.

Possible events may include:

Breweries / Dinners / Bowling & Billiards

Game Nights & Trivia / Movies / Hiking

Gold Membership ($80/Q, $250/yr)

All functions listed above, plus exclusive events catering only to Gold Members. Events will include more attention to ratios between men & women, age groups, and high end venues. Does not include cost of events or surcharges.

Possible events may include:

Boating / Wine Tasting / Tours & Museums

Parties / Fine Dining / BBQs / Antiquing

Gold with Match Dating ($80/mo paid quarterly)

Pricing includes all possible events listed, and at least 1 contact per month for possible dates set up with possibly compatible partners (blind dates) arranged according to criteria provided by members. Available ONLY as Gold Members. Does not include cost of events or surcharges.

List of events is not all inclusive. Some items may not be offered. Payments are for period selected, considered paid for full term without prorate or refund.
Membership Type *

Free Membership ( Free for each month.)

Full Membership Quarterly ( $ 36 for each three months.)

Full Membership Annually ( $ 125 for each year.)

Gold Membership Quarterly ( $ 80 for each three months.)

Gold Membership Annually ( $ 250 for each year.)

Gold Membership with Match Dating ( $ 240 for each three months.)
Add Me to...

I use Evite to notify singles of events and important information. I also send out a monthly newsletter of upcoming events and information on Central Coast Singles. I suggest you sign up for both to be informed.
Add Me to Evite Event Notices *
Be informed of events and receive updates for changes
Receive Monthly Newsletters *
Receive our monthly newsletters and any special notices
Any comments or questions?
We ask that you submit a picture for identification. Feel free to use the live cam on your computer or upload a CURRENT picture below. It is easier just to click the camera to take your picture. This is not used for the public. Thank you.
Say Cheese!
Upload MUST be CURRENT picture
Please submit picture no more than 1 year old
Picture is not for public display. We will use this picture ONLY to identify you and to use if you select the option of Match Dating. You may REPLACE this picture at any time by emailing ccoastsingles@yahoo.com
Signature
Signature date
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Central Coast Singles Membership Form

Memberships available (select below):