Fishing Trip Application
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Membership & Fishing Trip Application Form

(Please Type or Print) I hereby apply for membership in Cross Roads Athletic Club, Inc. for 2009 Name: Last First M.I. Address: No. Street Town Zip Telephone:( ) Date of Birth: Occupation: Blood Type: Color of Eyes: Color of Hair: Height: Weight: CPR Trained: Medical Requirements:(Allergies, Special Medication, Ect.)

You will need a New Hampshire Fishing License!

(We require each person to have a Valid New Hampshire Fishing License)

In Case of Emergency Notify: Address: Telephone: ( ) Relationship: Yes No Enclosed is .00 for 2009 Membership Dues. Yes No Enclosed is .00 deposit for this years Fishing Trip. I realize if I cancel before April 30, 2005, my deposit will be returned, less my .00 dues. I will send the balance before April 15, 2005 or I will not be allowed to attend. Yes No Enclosed is .00 the total amount for Membership and this years Fishing Trip. I’m an early bird and realize the same cancellation policy applies. Please read carefully before signing In signing this application, I hereby waive and release Camp Hale and Cross Roads Athletic Club Inc. and Officials from all claimsOf injury and/or damage incurred in connection with this Fishing weeked. The above facts are true to the best of my knowledge.All applicants must be at least 21 years of age. All new applicants must provide a copy of a valid ID for our records. Signature: Date: Email Address (If you have one): Mail checks to: Kevin Gallagher 38 Nevens Circle Rockland Ma 02370 New Member Sponsor: Member Since


Please disregard the year 2005 in the application, we are trying to fix iit to read 2007.

 

The new applivation is in the works!


 

 

Please make checks out to Cross Roads Athletic Club inc.

Send checks to Kevin Gallagher  38 Nevens Circle Rockland Ma. 02370

 

 

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