Membership Online - Central Pennsylvania Rock and Mineral Club

CENTRAL PENNSYLVANIA ROCK AND MINERAL CLUB, INC.
ONLINE MEMBERSHIP FORM

Full Year Membership (good from January 1 thru December 31)

SENIOR MEMBERSHIP . . . . . $ 15.00

JOINT MEMBERSHIP. . . . . . . $ 25.00 *
* For two adults

JUNIOR MEMBERSHIP . . . . . $ 7.00**

**(An additional $7.00 for each child 8 thru 17 years of age, added to an adult membership.)

(Note: There is a reduced membership rate for new memberships 7/1-12/31- Adult Rate $ 8.00, Joint Membership $ 16.00)

Type of Membership *

NEW
RENEWAL

Adults *

Last *

DOB *

First 2

Last 2

Birthdate 2

Junior Members

Junior Last

Junior DOB

Junior 2 First

A minor eight (8) through seventeen (17) years of age may join the club as a junior member under the sponsorship of an adult club member who is either a family member or legal guardian.

Junior 2 Last

Birthdate 6

Address *

Apt.

City *

State *

Zip *

Primary Phone *

Alternate Phone

Email *

Email 2

NOTICE: The club would like all members with internet service to receive their newsletter electronically. If this is not possible and you wish to opt out of receiving your newsletter via e-mail, please check here

I do not wish to receive the newsletter via email.

I hereby assume full responsibility for my actions and/or actions of Junior Member(s) as above, while participating in any activity sponsored by the Club. I release the Club, its officers and members, of any responsibility or liability for any personal or property damage that may occur while I/we participate in any club-sponsored activity. *

Signature(s)—Required of all Adults. Signature of an adult club member (either family member or legal guardian) is required for Junior Members.

Additional Information

Membership Renewal: Dues are due and payable before January 1. If not paid by the late payment date of February 15, all membership benefits will cease until payment is received. Renewal memberships are NOT prorated.