Membership Application Form

Date

Membership Type (select one)

Adult - $30/yr Junior - $15/yr Family - $60/yr

Application Type

NEW RENEWAL

Name(s)

Email (Please enter only one)

Member phone

Address (Street, City, State and Zip)

Junior Name(s) and Birthdate(s)

Emergency Contact Name

Emergency Contact Phone

Enter Total Membership Fees

Badges - Names -- $8 per Badge

Enter Total Amount Badge Fees

Currently we are unable to take payment online. A copy of this form has been emailed to you. Please print completed form and mail with payment to:

Maplewood Rock and Gem Club

8802 196th St SW

Edmonds, WA 98026