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Member Number # ____________

                            Membership Application

 

Name: ___________________________________DOB___________

 

 

Address: ________________________________________________  

 

________________________________________________________

 

Phone: __________________________________________________                    

 

Cell: ____________________________________________________          

 

Email: ___________________________________________________

 

Drivers License No#________________________________________

 

Emergency Contact Information: ______________________________

 

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For Members under the age of 18,

 

I, ________________________________________Member#________

 

am the parent or guardian of above registered child and a dues paying member of the Central Jersey Tractor Pullers Association. As the parent or guardian of child listed above I, fully understand that Central Jersey Tractor Pullers Association is not liable for injuries to the child.

 

__________________________________________________________

Signature of Parent or Guardian

Rev 2/14