Cooperative Membership Registration Form
Shangri La Care Cooperative, INC

This membership requires a one-time $300 fee to join. Each member has one voting share. To Join, fill out the application below, then send membership fee to:
SLCC, 428 Bryant Circle #246, Ojai, CA, 93023

First Name:
Last Name:
Zip Code:
Phone Number:
Email Address:
Date of Birth:
Drivers License/ID#:

I Agree:

Please choose a proxy:

If you are a Primary Caregiver, please enter your name:

*Please upload a scanned image of your
Medical Recommendation & a Photo ID below

Drivers License/ID:
Medical Rec: