G.E.A.R. MEMBERSHIP APPLICATION
PARENTS
NAMES:
________________________________________________
ADDRESS: _______________________________________________________
CITY: __________________ STATE: _______ ZIP: _______________
HOME PHONE: (____)_________________ WORK PHONE: (____)___________________
CELL
PHONE: (____)__________________ E-MAIL ADDRESS: ___________________________
_______________________________________________________________________________________
RIDER #1
$15.00 NAME: _____________________________ BIRTH DATE: _____________________
ABA SERIAL #: ____________________________________________________________
RIDER #2 $5.00 NAME: _____________________________ BIRTH DATE:
______________________
ABA SERIAL #: ____________________________________________________________
RIDER #3
$5.00 NAME: _____________________________ BIRTH DATE: ______________________
ABA SERIAL #: ____________________________________________________________
RIDER #4
$5.00 NAME: _____________________________ BIRTH DATE: ______________________
ABA SERIAL #: ____________________________________________________________
$15.00 FOR THE 1ST RIDER PER IMMEDIATE FAMILY/ PER YEAR
$5.00 ADDITIONAL FOR EACH RIDER THEREAFTER PER IMMEDIATE FAMILY/PER YEAR
By signing you acknowledge you have received the G.E.A.R. handbook.
Parent or rider 18 years or older signature:
_________________________________________________________ Date: ____________________
PAID Yes/No (please circle) Cash or Check RECEIVED BY: ________________________________________
-------------------------------------------------CUT
HERE---------------------------------------------------------------------------------------------------------------
$15.00 for 1st rider PER IMMEDIATE FAMILY/ PER YEAR
$5.00 additional for each rider thereafter PER IMMEDIATE FAMILY/PER YEAR
*
G.E.A.R. MEMBERSHIP RECEIPT for Emery Park BMX
PAID YES NO (Please Circle)
DATE:
__________________
CHECK #: _____________
CASH RECEIVED BY: ____________________________________________