4xFools Membership Application

 Member (Head of household must be over 17)
Application Date :_______________________________________________________________________
Club Sponsor :_______________________________________________________________________
Address :_______________________________________________________________________
City :_______________________________________________________________________
State :_______________________________________________________________________
Zip :_______________________________________________________________________
Anniversary (opt) :_______________________________________________________________________
This membership covers:

Name

Birthday (opt)

Home #

Mobile #

Work #

Email
           
           
           
           
           
           

Vehicle
 

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Make

        

Model

        

Year

        

License

        

First Aid Kit (y/n)

        

Extinguisher (y/n)

        

CB Radio (y/n)

        

Modifications:

        
         
         
         

Medical
For each person, list medical conditions and drug or insect allergies that may arise on an outing. ____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
Emergency Numbers

Name

Relationship

Home #

Mobile #

Work #