Number of Women & Girls Included in Registration: | |
| Date of Birth for each Registrant: | |
Delivery Day of the Month: (see below for assistance) | |
First Name of Primary Account Holder: | |
Last Name of Primary Account Holder: | |
Delivery Address Street 1: | |
| Address Street 2: | |
| City: | |
| Zip Code: | (5 digits) |
| State: | |
| Daytime Phone: | |
| Evening Phone: | |
| Email: | |
| |
By typing my name I agree to the Delivery Chicks terms of Registration: $24.95 to join per household payable with my first shipment, & never any fees! | |