Mid-America Membership Application

 

___ Check here if new member

 

___ Check here if renewal

 

Please enroll me as a member of the Mid-America Chapter of the Cushman Club of America.

 

My membership (dues of $10) are enclosed which entitles me to receive a current year membership roster and four newsletters with free advertising privileges of Scooter related items in each newsletter.  Membership year is from September to September and is not prorated.  Make checks payable to:  Mid-America Cushman Club.

 

By my signature hereon, I agree to release the club from any claims of accidental injury or any liability at or during any club meets.

 

Signature _________________________________________________

 

Date _____________

 

PLEASE PRINT

 

Name(s) __________________________________________________

 

Phone _____________________ e-mail_________________________

 

Address ___________________________________________________

 

City, State, & Zip___________________________________________

 

Send applications  & dues to:             Bob Weltig

                                                            Box 306

                                                            Dalton City, IL 61925