Membership Form 2012-2013
Please select a membership category:
_____ Active: Spouses of active-duty military personnel (“MP”), including foreign military assigned to the Pikes Peak Region (“PPR”),
Spouses of Guard and Reserve
_____ Associate: Adult relatives of MP; spouses of retired MP; civilian personnel (“CP”) assigned to Pikes Peak Region; spouses of CP-active
and retired- assigned to the PPR; active duty MP assigned to PPR; retired MP; spouses of MP who are listed as MIA;
widows/widowers of MP of the Armed Forces; unmarried former spouses of active or retired MP who are eligible for military-related
privileges under the Former Spouses’ Protection Act.
_____ Honorary: As invited by the PSC
Annual dues for Active and Associate members are $30.00 for the twelve month period beginning September 1 st.
Please make checks payable to: “PSC” Mail the completed form with your dues to: Peterson Spouses’ Club, 260 Glasgow
Ave. Bldg 1013, Colorado Springs, CO 80914 Attn: Membership
Member Name _______________________________________________________ Phone _______________________
City ______________________________________________ State _________ Zip Code ________________________
Birthday (mo/day)__________________________ Anniversary__________________________
Sponsor’s First Name / Unit /Base_____________________________________________________________________
Please send me the monthly PSC newsletter by (check one): email ______________ regular mail ________________
Sub-Club interests (please check all that apply or list your own): □Book Club □Daytime Bunco □Evening Bunco
□Couponing □Day trippers □Gourmet Group □Lunch Bunch □Mahjong □Movie Club □Paper Crafts
□Playgroup □Scrapbooking □Shopping □Tea Time □Quilting Club □Wine Tasting □Other______________________
Please read and initial the following statements to indicate your consent:
_______ I understand that if I make reservations for a PSC function for which there is a cost to attend and I do not cancel by the
RSVP date, I am still responsible for payment. The PSC will make every effort to replace my reservation with a walk-in attendee.
_______ I understand that the information provided by me on this form may be reproduced and distributed to the members of the PSC
in the form of a membership directory, e-mail alerts and reminders for PSC functions, mailing lists for PSC publications, and other
purposes of PSC business. Your personal information will not be sold; it is for club business only.
______The following information WILL be published in the membership directory. Please circle those item(s) you wish NOT to be
published: (Please circle all that apply) phone number address email address
______ I understand that membership information contained in the membership directory, email distribution lists, and board rosters
are for official PSC use only. This information may not be used to forward chain emails, or to promote personal businesses, causes,
or political views.
______I understand that photos may be taken at various functions of the PSC. By initialing here, I give my permission for my name
to be utilized captioning these photos for PSC publications.
____ I understand my rights and obligations as a PSC member as stated in the PSC Constitution and By-Laws and PSC Charitable
Organization By-Laws (viewable at www.petersonspousesclub.com). To obtain a written copy of these documents, please contact the
PSC president at email@example.com.
You may purchase a personalized name tag for an additional $5.00. YES_____ NO_____
Signature (required) Date