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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