Membership Application
(If Family Membership, Name and Birth Date of Each Member)
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Last Name		 ______________
First Name		 ______________
Middle Name		 ______________
Date of Birth
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Last Name		 ______________
First Name		 ______________
Middle Name		 ______________
Date of Birth
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______________
Last Name		 ______________
First Name		 ______________
Middle Name		 ______________
Date of Birth
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______________
Last Name		 ______________
First Name		 ______________
Middle Name		 ______________
Date of Birth
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____________________________
Address		 ____________________________
City/ State/ Zip Code--
____________________________
Home Phone
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Work Phone
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__________________________________________        _____________________________
Occupation                                                                            email address
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Please Check Below:
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Runner _____   OR    Walker  _____
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New Member  _____   OR    Renewal  _____
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Family Membership _____  OR    Individual Membership  _____
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I would like to serve on one or more of the following committees:
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Membership_____    Race_____    Special Events_____    Newsletter_____
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Other Areas of Interest: ______________________________
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Membership dues are paid each January and entitle you to one full year of membership.  The following schedue may be used if you are beginning membership within a calendar year.
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January - December Membership $20.00 for family $15.00 for individual
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Donation to support 
Scholarship Program		 $ _____________________
Amount Paid $ _____________________

Please mail the form to:
Greater Evansville Runners/Walkers Club (GERWC)
PO Box 3835
Evansville, IN  47736-3835
Make checks Payable to:
Greater Evansville Runners/Walkers Club (GERWC)