NORTH EAST MOTOCROSS CLUB
Membership Application

Name:

Address:

E-mail Address:

Other Family Riders Name(s):

Emergency Contact:
(name & home/cell numbers)

Health Insurance Company & Policy Number:
(attach a copy of your valid insurance card)

Please Circle Your Membership Choice:

1 YEAR FAMILY MEMBERSHIP: $1200.00

1 YEAR SINGLE MEMBERSHIP: $800.00

1 YEAR RACER MEMBERSHIP: $500/each
* Minimum three racers -you and two friends- Monday through Thursday only

Membership run from April 1st to March 31st --rates will be prorated appropriately.

Membership fees must be submitted, in full, at the time of application.
Make checks payable to: NE MX Club LLC

A list of rules will be provided to you and they must be adhered to, no exceptions.
All infractions will be reviewed and discipline action may be taken.

Signature indicates you understand you must abide by the NE MX Club's rules and the above information is true.

Signature:                                                                       Date: