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Membership Form

Name__________________________  Age _____   Birthdate_____/____/______

Name__________________________  Age _____   Birthdate_____/____/______

Name__________________________  Age _____   Birthdate_____/____/______

Name__________________________  Age _____   Birthdate_____/____/______

(List only those family members who attend CCRC events as participants or helpers.  If more than four members of your family are CCRc members, please write their name and ages on a separate sheet)

Address______________________   City __________________ State _______ Zip _______

Home Phone ______________________   Work Phone_______________________

Annual Dues                                               

________ Person $10

________ Family/Couple $20                           ____ New Membership  or  _____Renewal

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Gregg Nelson, 1260 e Spencer ct
la center wa 98629