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Culpeper Recreation Club Membership Application - DOC

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					                  Culpeper Recreation Club Membership Application
To: BOARD OF DIRECTORS
    Culpeper Recreation Club, Inc.
    P.O Box 249
    Culpeper VA. 22701
    (540) 825-8269

From:
          Last Name                                      First Name                               M.I.


Spouse’s Name:

Address:
                    Street/ P.O Box


                    City                                         State                 Zip Code

Phone:                                                           Email Address:
                                                                      (Required)

Please enter my name as a member of Culpeper Recreation Club, Inc. I have selected the following month
to become a member.
Note: Applications are accepted only for that month with proper postmark and payment.

                                                      Initiation Fee
_______ January $75.00                                                     _______ July $650.00
_______ February $175.00                                                   _______ August $650.00
_______ March $275.00                                                      _______ September $650.00
_______ April $375.00                                                      _______ October $650.00
_______ May $475.00                                                        _______ November $75.00
_______ June $650.00                                                       _______ December $75.00

Membership dues are annual; may be paid in monthly installments. Pay for 11 months get the 12th
month free.
_______ Family Membership $55.00 Per month (660.00/year)

_______ Family Plus Membership (with Grandparents) $60.00. Per month (720.00/year)

______ Single Membership $50.00 Per month (600.00/year)
_______ Senior Membership (65 years or older) $45.00 Per month (540/year)


Babysitter pass available. See manager for details.
                                                                                                         Page1of 2
                                    Children/ Legal Dependents:
  (Persons named must be 21 or younger and be eligible to be claimed as dependents on Federal Income Taxes )

      Name                                                     (DOB)           Relationship
______________________________________                        _______        _________________
______________________________________                        _______        _________________
______________________________________                        _______        _________________
______________________________________                        _______        _________________
______________________________________                        _______        ________________


  Grandparent’s Name if Family Plus__
_____________________________________
_____________________________________
_____________________________________
_____________________________________


How did you find out about our Club?
______________________________________________________________________________
______________________________________________________________________________

Did a current member refer you to the club? No_____ Yes_____
If Yes, one member name & club number_________________________________________

Initiation fee due today $_________ Check enclosed____ Credit Card payment preferred____
Note; Payment by credit card is done on line, DO NOT INCLUDE CARD INFORMATION,
you will receive an on line bill via your Email address.

I understand that I will be E billed for my monthly dues starting the month following my
initiation.



_______________________________                                        ______________________
                 (Signature)                                                        (Date)



New, first time, members check out the Barnstormer Special for our summer swim team.
Contact Treasure@culpeperrecclub.com


Thank you for your application. It will be reviewed by the board and you will be notified as soon as possible

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posted:7/25/2011
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