Membership Application

Membership ensures that our club stays open.

Please complete this form and return to the food service counter or mail to the Club.

PLEASE PRINT

Date:__________________________

Name:_________________________

Address:_______________________

City:__________________________

State:___________  Zip:___________

Home Phone:____________________

Cell/Work Phone:_________________

E-Mail:________________________

MEMBERSHIP TYPE:

Regular Annual  $200 (Save $40 year)  __

Regular Monthly $20 per month             __

Regular 6 Month $110 (Save $10 year)  __

Senior (65 and over)  __ Junior (Under 18) __

Annual  $100 __  Monthly $10 __

Non-Resident Annual $25 __

Credit cards or checks accepted.

OPTIONAL INFORMATION

Do you have a talent or skill that you would like to volunteer? _________________

___________________________________________________________

Would you like your sobriety date published in the newsletter?  YES __   NO __

Sobriety date_____________

Office Use Only:

Date Card Sent:__________________

Member Number:_________________