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Coastals Mail Membership Application

MAIL FORM AND PAYMENT: Please complete the application below and print it out. Sign and mail the application with a check for the first year's dues of $20.00 to: Coastals, PO Box 4683, Charlottesville, VA 22905.

Information listed here is only for club use and will not be provided to any other group for any purpose.

This information will be published in the annual Roster.

Full Name*

Name(s) of family member(s)

Address*

City*
  State*   Zip*   
Home Phone (including area code)

Office Phone

Cell Phone

Email*

CaNews Option*
   

   

Directory Option*
   

   

NOTE: If you move, please let us know your new address including a new phone number. This will enable us to update our Membership Directory and redirect your CaNews if you chose the mail option.

1. What type of boat or boats do you own?

2. What is your skill level? Beginner Intermediate Advanced Expert

3. What would you like from the club?

4. How did you hear about us? If someone referred you, please give their name here.

5. What is/are your Coastals Forum user name(s)? Please list each family member and their user name. You must register on the Forum before filling in this field.

I hereby state that I have read and agree to abide by the American Whitewater Affiliation Safety Code for all Coastal Canoeists trips on which I am a participant. I understand that I am responsible for my own safety on club trips and that Coastal Canoeists is a voluntary association and coordinates trips and other activities only.

Signature_________________________________________ Date________________________

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