Lakeshore Sports Car Club
Affiliate – MIDWESTERN COUNCIL OF SPORTS CAR CLUBS
MEMBER APPLICATION AND INFORMATION FORM
NAME: ______________________________ SPOUSE'S NAME: ____________ _____
BIRTHDATE(s) (Month/Day Only) ________________________ __
CITY, STATE, ZIP ____________________________________________________________
(Home) ____________________ (Work) ___________________ (Cell) ________________ __ _
TELL US ABOUT YOURSELF:
DO YOU HAVE A RACECAR? __________________ TYPE \ CLASS ___ ______________
WHAT ARE YOUR INTERESTS IN RACING?
PLEASE CHECK ALL THAT APPLY:
RACE STAFF ROAD RACING
HIGH/LOW SPEED AUTO X VINTAGE/HISTORIC
SEND APPLICATION AND CHECK PAYABLE TO "LSCC" TO:
Stephanie Andersen, LSCC Membership Chair
900 Kingston Ave.
Racine, WI 53402
For membership related questions/inquiries, contact Stephanie
via phone (cell): (262) 880-9630 (5 pm to 9 pm on weekdays)
or e-mail: firstname.lastname@example.org
Dues: Member - $45.00
New Renewal - $45.00
Spousal/Family - $5.00 *** MC Club Member - $5.00 ***
If renewal, what year did you first join Lakeshore: _____________
*E-mail address is required because LSCC monthly Newsletters and other communications are sent via e-mail.
*** Provides liability insurance coverage as a member at LS sponsored events. Meant for those who do not need
MC racing points, or who do not hold a position as an Officer. MC mailings are also not included. Dual member-
ship is for those who list another MC club as their club of record, but wish to be on our mailing list.
MEMBERSHIP FORM 2011
Office Use Only: Paid ck# ______________ Card _____ Letter _____ Decals _____ Patches (1L-2S) _____ Updated List ______