Membership Application/Renewal Form by gcpCOvQ

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									                  Membership Application/Renewal Form

Please fill in completely if you are a new member. If you are renewing membership you need
only fill in any changes and payment information.

First Name:_______________________ Last Name:____________________________
Family names also joining:_________________________________________________
____________________________________________________________________
Address:_________________________________________
         _________________________________________Zip:_________________
Alternate address:__________________________________
                   __________________________________Zip:_________________
Phone:_____________________Cell Phone____________________
Email Address:________________________________________________________
Would you like to receive the newsletter by: {} Email {} Pick up at club {} mail

Optional Information:
Birthday: Month__________Day_______ Spouse’s Birthday: Month________ Day_____
Special Interest:_______________________________________________________
Would you like to volunteer for: {}Shop Supervisor {}Club Officer {}Librarian {}Maintenance
Other________________________________________________________________

Payment Information:
Please choose one: {} Single membership $12/yr {} Family membership $18/yr
Please choose one: {} Paid in cash {} Paid by check (Payable to Four Corners Gem and Mineral Club Inc.)
Amount:______________       Check #___________________


Signature:________________________________________Date_______________

Shop Release of Liability:

If you plan on working in the shop, please read and sign below.

I hereby release, hold harmless and indemnify the Four Corners Gem and Mineral Club,
Inc., its Board of Directors, officers, and members from any liability for any personal
injuries I may sustain or any damage to my property while working with the shop
equipment, including saws, sanders, grinders, other tools and any other materials used in
the Four Corners Gem and Mineral Club’s workshop (hereinafter “workshop”). I
understand that I enter the workshop and operate the above equipment and tools and
utilize the above materials in the Four Corners Gem and Mineral Club Clubhouse at my
own risk.

Signatutre____________________________________________Date________________

								
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