Be a YumiGirl/Guy

YumiClub

Application Form

Please fill in the following application. Fields marked with a '*' are required. (All your information will be kept confidential, we promise. Cross our heart.)

First name *
Last name *
Email *
Street Address *
City *
Post/Zip code *
State *
Country *
Telephone Number *
Mobile Number *
Birthdate *	Date Month Year
With which Company or School are you affiliated? *
Name
City
State
Country
How did you find out about Yumiko?
Do you own any Yumiko pieces? *   0-5   5-10   full closet
What is it about Yumiko you like?
Do you know about Yumiko Takeshima the dancer/designer?
No   Yes
How did you find out about becoming a YumiGirl or YumiGuy?
Do you have regular access to a computer? *   No   Yes