2025 JCYM Membership Renewal with Password

JCYM Annual Membership Renewal Web Form
Must be completed each year by ALL MEMBERS and received no later than March 1st.

Renewal Form & Dues RECEIVED after March 1st are subject to a $25 PENALTY FEE.

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SUBMIT AND PAY ONLINE or submit online and pay by check.

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Committee assignments are given on a 1st come, 1st served basis

when completed FORM & PAYMENT are received.
JCYM Code*
Correct pass word (Code) is required, see page 44 in Yearbook. DO NOT USE "ENTER BUTTON"
Select Last, First*
Select name
Click in the box on the left, then click your name
and it will appear in the box below.
Last First
First Name*
DO NOT TYPE NAME, it should already be filled in.
Last Name*
Date Recd

MonthDayYear
Hour MinutesAM/PM Option
Check #
Amt Recd
Status Ckd

Ckd
Note
Spouse/Partner*
Street & Apt/Unit #*
ex: 3509 W 97th Street #141Overland Park KS 66206-2063(Spell out: Avenue, Terrace, Place, Road, etc.)
City*
State*
9 digit Zip Code *
Home Phone
Cell Phone
Email
example@example.com
Alternative Address

Check to provide ALTERNATIVE ADDRESS
Effective Dates of Alternative Address
2nd Phone
2nd Street & Apt/Unit #
ex: 3509 W 97th Street #141Overland Park KS 66206-2063(Spell out: Avenue, Terrace, Place, Road, etc.)
2nd State
2nd City
2nd 9 digit Zip Code
Emergency Contact Information
Emergency Contact 1 First Name
Emergency Contact 1 Last Name
Emergency Contact 1 Relationship
Emergency Contact 1 Phone
Add phone number
Emergency Contact 2 First Name
Emergency Contact 2 Last Name
Emergency Contact 2 Relationship
Emergency Contact 2 Phone
Add phone number
Did you make changes to ANY of the above information?*

NoYes
Current Membership Status*
Renewal Membership Status*
REQUIRED to select
Supporting Type Last year
If you qualify for Supporting select one of the following

10 total years of Active Status MembershipEmployed 25 hours per weekFull Time StudentFull-Time CaregiverCombined Caregiver/Student/EmployedSpecial circumstances approved by Executive Committee
Please provide details for the following catagories:

Employed: 25 hrs per/wk, employers name, address and phone
Full time Student: 12 credit hrs per/semester, school and course of study
Full time Caregiver: of small children or special needs child or adult
Combination of caregiver, student, employed
Detail for Supporting Status*
For Inactive Status or Supporting Status - Special Circumstances:Describe special need that prevents your participation*
Yearbook Photo

None SentEmailed to jcympatty@aol.comMailed - to: Patty Gay, 32100 W 143rd, Gardner KS 66030
Club Committee Assignments
CLUB COMMITTEE assignments are given in the order they are received - 1st come, 1st served!

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ACTIVE members are required to serve on one Club Committee

SUPPORTING members may choose to serve on one Club Committee as one of their required options

EMERITUS members are encouraged to participate.

CONTRIBUTING members are encoraged to participate.

Club Committee Chairs should list their Club Committee as their 1st choice.

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Please select 3 different Club Committee Choices.

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1st Club Comm Choice
2nd Club Comm Choice
3rd Club Comm Choice
Are you willing to serve on more than one Club Committee?

I WILL serve on 2 Club CommitteesI WILL serve on 3 Club Committees
The following committee positions are determined in accordance with the bylaws or Presidential appointment. If you are interested in being considered, check all that apply.

FinanceJCYM Charitable Gift FundJCYM ScholarshipIT (Information Technology)Press (Yearbook & Scroll, Mailing if necessary)SteeringUnderwritingWays and Means
Please provide further information if needed:
Philanthropy Committee: If you choose the Philanthropy Committee you must list 3 different projects that you would be interested in co-leading (all members of this committee will co-lead a project). Assignments are not guaranteed. Projects are subject to change.
1st Project Choice
2nd Project Choice
3rd Project Choice
Would your home or club house be available for any of the following events?

JCYM Informational Tea (Sept.)New Members’ Brunch (Feb.)Provisional Orientations (Feb., Mar., Apr.)Day/Night Activities
If you are willing to sponsor JCYM at your Country Club/Club House please provide the name below.
Country Club/Club House affiliations
It would greatly help our Nominating Committee if you are interested and would accept a nomination for any of the elective positions listed below. This could be for the current year or possibly upcoming years. Mark all that apply.

President ElectFirst VP - MembershipSecond VP Elect - PhilanthropyWays and Means ElectTreasurerWays and Means TreasurerRecording Secretary
(This information is not considered a committment and will not be published)
Active - $175

Operations Assessment $75
Ways & Means Assessment $75
Facility Assessment $25
Supporting - $137.50

Operations Assessment $75
Ways & Means Assessment $37.50
Facility Assessment $25
Emeritus - $100.00

Operations Assessment $75
Facility Assessment $25
Inactive - $175.00

Operations Assessment $75
Ways & Means Assessment $75
Facility Assessment $25
Non-Resident - $25.00 (Members in good standing with an established legal residence elsewhere)
Contributing - $350

Operations Assessment $100
Ways & Means Assessment $250
Renewal Amount
Charitable Donations

Now is a great time to give your financial support!
- The success of our Ways & Means fundraising efforts relies on donors like you.
- The Charitable Gift Fund is a perpetual fund which allows JCYM to greatly impact our Philanthropies now and well into the future.
- Your support of the Scholarship Fund will help deserving students connected with our Philanthropies fulfill their educational dreams.
W&M Donation (fill in dollar amount)
Ways & Means Donation
Ways & Means Donation - In Honor Of
Ways & Means Donation - In Memory Of
Please Note:

If you would like the person, or family of the person, you are giving your donation in Honor of or in Memory of, to receive a note of your generous kindness please list a name and address for us. Thank you.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CGF Donation (fill in dollar amount)
JCYM Charitable Gift Fund
JCYM Charitable Gift Fund - In Honor Of
JCYM Charitable Gift Fund - In Memory Of
Please Note:

If you would like the person, or family of the person, you are giving your donation in Honor of or in Memory of, to receive a note of your generous kindness please list a name and address for us. Thank you.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Schol. Donation (fill in dollar amount)
JCYM Scholarship Fund
JCYM Scholarship Fund - In Honor Of
JCYM Scholarship Fund - In Memory Of
Please Note:

If you would like the person, or family of the person, you are giving your donation in Honor of or in Memory of, to receive a note of your generous kindness please list a name and address for us. Thank you.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Magnetic Name Tags $15

Members: To order and purchase additional name tags fill in number of tags you would like. Fill in your name as you would like it to appear on your name tag.
Number of Name Tags
Name Tag Cost
Name on New Name Tag
Date - late fee added after

MonthDayYear
Date
Late Fee
After March 1st a $25 PENALTY FEE is added..............................
Total Due
Credit Card Due
Pay your renewal fees, donations or name tags SECURELY via PayPal

or as a "Guest" with your credit card.

You do NOT need to have a PayPal account to pay online.

You may also pay by check.

PayPal is our credit card processor.

The name “Johnsoncoun” will be shown on your credit card statement because it truncates Johnson County Young Matrons.
Click to select payment method*

By Check: Click Submit, Mail Check to: Patty Gay, 32100 W 143rd St, Gardner, KS 66030-9727Pay Online
Pay Online

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USDRenewal Payment
- If you would like to print this form please do so before clicking the "Submit" button.
- You will receive an email from JofForm which is confirmation you have completed your JCYM Membership Renewal.
- If you paid online you will also receive an email from PayPal to show your payment has processed.
Are you ready to submit?*

Yes
BE SURE TO CLICK THE SUBMIT BUTTON TO COMPLETE THIS PROCESS!
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