Date Completed:______________________ New:___________ Renewal:__________

Name:________________________________________ Date of Birth:______________

Address: _______________________________________________________________

Address 2: ______________________________________________________________

City:_______________________________________________ State_______________

Home Phone:________________________ Emergency Number:_________________

Email:____________________________________________ (will not be publicized)

Membership runs from April 1- through March 31 of following year regardless of when received.

_____ Check here if you are willing to let us release your phone number to other club members so they can contact you about paddling events or opportunities to paddle. It will not be released for other reasons.

__________ If you would prefer to be contacted by email, check here.

__________ Do you have any medical condition / and or a prescribed medication that may impact on water activity of which we should be aware? Please describe below, use back if needed.