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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