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Date
Organization (Race Sponsor, Club Affiliate,  Business Affiliate)
Last Name
First Name   Middle Name  
Address
City State  
 Zip Country (Non-US)  
Telephone    EMail Address
Date of Birth

Membership: New member   Renewal  

Member Type

Price
Governing, 18 & Over $20.00
Family $25.00
Junior, 5-17 $ 7.50
Race Sponsor $ 30.00
Club Affiliate $ 30.00
Business Affiliate $ 30.00
Foreign (US funds only.)  Canada/Mexico: Add $5.00; All others add$10.00
For family membership - other than above member, please complete the following:
NAME

              BIRTH DATE

Total Amount Enclosed:    Recruited by
Print and send membership form to:
Paula Thiel
487 Wylie School Rd
Voluntown, CT 06384