Please PRINT neatly
New or Renewal (please circle one)
Start Date: ___________________
Referred by:__________________________________________________________________
Name(s):_____________________________________________________________________
Childrens names and date of birth:
Address:_____________________________________________________________________
City/State/Zip: ________________________________________________________________
Telephone: _________________________
E-mail: ____________________________________
Mail to: Cindy Cameron
2650 SW 23rd St.
Lincoln, NE 68522-1837
Individuals 19 and over by Jan. 1st must have their own membership.