White River Roadrunners

Application for Membership

Name:________________________________________________DOB:__________

Address:______________________________________________________________

City/State/Zip:_________________________________________________________

Phone: ______________________(Home) _______________________(Work)

E-mail:____________________________________________________________

Runner: __________________Walker:________________ T-Shirt Size:___________

Place of Employment:________________________________________________

Spouse/Children (for family membership):

Spouse:______________________________________________ DOB:___________

Child:________________________________________________ DOB:___________

Child:________________________________________________ DOB:___________

Child:________________________________________________ DOB:___________

Annual membership dues: $15/Individual or $25/Family*.

Prorated club dues: (If you pay within one of these months, then your dues will be:)
 
  January - April:  $15 individual     $25 family
  May - August:   $10 individual     $15 family
  Sept - Dec:        $5  individual     $10 family

Make checks payable to:

White River Roadrunners, 169 W. Ross St. Batesville, Arkansas 72501

Signature_______________________________________Date________________

* - Family is interpreted as all immediate family members living in the same household.