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FLATLANDERS JEEP CLUB

C/O Colleen Strnad
1027 E. 1292 Rd.
Lawrence, Kansas 66047
Phone: 785-842-5814

 

MEMBER INFORMATION SHEET

 

NAME:_____________________________________________

SPOUSE:__________________________________________ 

ADDRESS:__________________________________________

CITY: ___________________________ STATE:________

ZIP CODE: _________

PHONE NUMBER: ______-______-__________

EMAIL: _________________________________

JEEP YEAR: __________MODEL ___________

SPECIAL EQUIP:  WINCH ___  LIFTED ___ 
TOW POINTS (FT) ____ (R)____
CB ___  ROLL BARS (FT) ___ (R) ___ 
SEAT BELTS ____ FIRE EXT. ____
LOCKERS (FT) ____ (R) ____ TIRE SIZE ____

What type of activities would you like to see our Club conduct or get involved with:____________________________________

________________________________________

How or who referred you to our Club:______________________________________

 

I understand that off-road vehicle operation can be hazardous, and accidents can occur which could result in either personal injury and or vehicle damage.  I hereby agree to hold harmless all Officers, Representatives and Agents of the Flatlanders Jeep Club and acknowledge that I accept all risks involved in participation in activities sponsored by the Flatlanders Jeep Club.

SIGNATURE:

_____________________________________ 

DATE: ____________________

 

If under 18 years of age, this form must also be signed by legal parent or guardian:

PARENT/GAURDIAN: _____________________________________

DATE: ___________________

ADDRESS & TELEPHONE Number ________________________________________

 

Club dues are $24.00 a year due on September 1^st.  Dues are pro-rated depending on the month you join. 

Webmaster July 1, 2008 22:41