MEMBERSHIP APPLICATION

L Street Running Club
MEMBERSHIP APPLICATION / RENEWAL FORM

RENEWALS: ---------- Individual $20 Family $25

New Members: --- Individual $45 Family $50

Please Print all Entries Clearly

Last Name:______________________________________

First
Name__________________________

Male [ ] Female [ ] Additional Contribution to the LSRC Charity Fund $

                        List First Name of any Family Members (Spouse and Children 18 years old or younger)
                             to be included in the Family Plan

Name Age

_______________________________ ______

Name                                                             Age

_______________________________              ______

___________________________ _____

Your Contact Information

Street: _________________________________________________

Apt #:

City: ________________________________

State:

Zip:

Home Phone

Office Phone:

E-mail address _______________________________________________________________________

Make checks payable to: L STREET RUNNING CLUB and Please mail to:

                                                           L Street Running Club Membership
                                                           c/o PO BOX 445
                                                           South Boston, MA 02127