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                               Membership Application

Name ___________________________________    Spouse _________________________________

Birth Month & Day ________________________    Birth Month & Day _______________________

Address ___________________________________________________________________________

City ________________________  State ______________________  Zip ______________________

Phone _______________________________   Email ______________________________________

             Children                                                   Birth Month & Day

1. _________________________                           _____________________________

2. _________________________                           _____________________________

3. _________________________                           _____________________________

4. _________________________                           _____________________________

Annual Dues ---- Payable on October 1st each year for the next calendar year

Single Membership                         $11.00

Couple/Family Membership           $16.00

Junior Membership                         $5.00

Junior members less than 16 years of age must be supervised by an adult relative or designated Club Member. 

Club Name Tags --- May be ordered for a fee of $------ each. Please print clearly on the lines below the name required on each tag.

1. ________________________________             2.__________________________________

3. ________________________________              4.__________________________________

5. ________________________________              6. __________________________________

Signed 

  ____________________________________         Date  ______________________________

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