The St.Charles Sportsme
s C.ub
ANNUAL JUNIOR MEMBERSHIP RENEWAL FORM
(aI/fields must be completed)
Date of Application:
Name:
Address:
Street
Are you a U.S. citizen? Yes D No
State
City
Are you a N.R.A. Member'! Yes D No
D
ZIP
0
Have you passed a Hunter Safety Course? Yes 0 No 0
If yes, card J.D. Number:
{Junior Members must pass a Hunter Safety Course within one year of applicationfor Junior Membership.}
Do you have aF.O.J.D. Card? Yes
0
No
0 \.
If yes, card J.D. Number:
What do you expect to get from your membership?
How can you contribute to the club?
What sporting activities are you interested in? Trap
Other:
0
Skeet
0
Sporting Clays
0
Riflery
0
Fishing
0
Applicant's Signature:
--------------------------------------------------------------------------------------------------SPONSOR INFORMATION
Sponsor's Name (please print):
Are you a current member of the-St. Charles Sportsmen' s Club: Yes 0
What is your relationship, if any, to the prospective junior member?
--
-- --
-- --
No
0
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--
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PARENTAL PERMISSION AND WAIVER
I,
, certify that I am the parent or legal guardian of the above-named applicant. My son/daughter makes this
application with my permission and approval. My son/daughter has my permission to participate in activities with the Junior Members of the
St. Charles Sportsmen's Club. While using Club facilities or participating in said activities, I hereby waive and agree to hold harmless the St.
Charles Sportsmen's Club, its members, officers, directors, and such persons supervising Junior activities from liability for injury and/or illness
arising from such use or participation. Further, I certify that my child is covered by a policy of medical insurance sufficient to ensure treatment
in the event of illness or mishap while under the supervision of said persons. In the event of accident or illness, I authorize the responsible
group leader to seek emergency medical assistance on behalf of my child and make necessary decisions for emergency treatment. In the event
that emergency treatment is rendered under this provision, I agree to be responsible for payment of all costs so incurred.
Policy Information:
Pmvider
Group Number and Name
J.D. Number
Parent(s) name(s)
Address and phone if different from above:
Parent(s) signature and Date:
Junior members must be under 18 years of age. Junior membership will be extended to age 21 if the applicant is a full-time student.
--------------------------------------------------------------------------------------------------For Club Use only
$25.00DuesPaid-"-"_
Received by:
..