(Print, fill in, and mail to address on home page)

Last Name_________________________First__________________Spouse________________

Address_____________________________City/State___________________Zip___________

Home Phone____________________ E-Mail Address__________________________­____

Names of your children and their ages (if family membership)

______________________________________________________________________________

______________________________________________________________________________

Husband/Dad Work Place__________________________________________________­­­­­___­­__

Husband/Dad Work Phone ______________________ Cell or Pager #____________________

Wife/Mom Work Place__________________________________________________________

Wife/Mom Work Phone_________________________ Cell or Pager #____________________

Please list 2 emergency contacts with phone and or cell numbers that are different than those
listed above.

_____________________________________Phone #______________Cell #_______________

_____________________________________Phone #______________Cell #_______________
List any Emergency Information on any persons listed above (i.e.; bee stings, allergies, and treatments):

______________________________________________________________________________

______________________________________________________________________________
Choose one:
Family Membership    ____ $300.00 before 4/15/07 ____$350.00 after 4/15/07
(2 or more people who live in the same household)
Single Membership      ____$ 175.00 before 4/15/07      ____$ 200.00 after 4/15/07
(1 person of any age)

Date sent in______________  Check #___________ or Money Order #____________

Please mail to: 3645 East Main St.  #104  Richmond, IN  47374