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FLINT HILLS 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 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/GAURDIAN: ____________________________ DATE: ____________
ADDRESS & TELEPHONE No. ________________________________________
Club dues are $24.00 a year from September 1st —August 31st of the following year.Dues are pro-rated at $12.00 for a partial year only from March 1st or any other subsequent month through August 31st.
Webmaster
August 16, 2012 22:06