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

MEMBERSHIP REGISTRATION
Please include dues payment when submitting registration form

     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 did learn about, 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 Flint Hills Jeep Club and acknowledge that I accept all risks involved in participation in activities sponsored by the Flint Hills Jeep Club.

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

PARENT/GUARDIAN: _____________________________________ DATE: ____________
ADDRESS: ________________________________________________________________
CITY: ________________________________ STATE:________ ZIP CODE: ____________
EMAIL: ___________________________________________________________________

DUES PAYMENT INFORMATION:  Membership dues are $24.00 a year (September 1st - August 31st of the following year).  Dues are pro-rated at $12.00 for those sending in their registration March – August.  For membership to be complete, payment must be received with this form.    

Webmaster November 3, 2013 15:11