Roxanna Club Application

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Roxanna Club Membership Application

Application Date: ______/______/_______
Name: ________________________________________________________________________
Spouse/Partner Name (if Family Membership): _______________________________________
Children's Names & Dates of Birth (if Family Membership):
_____________________________________ ______/______/_______
_____________________________________ ______/______/_______
_____________________________________ ______/______/_______
_____________________________________ ______/______/_______
Address: ______________________________________________________________________
___________________________________________________________________________
Cell Phone: ______________________________ Home Phone: _________________________
Cell Phone: ______________________________ Other Phone: __________________________
Email: ________________________________________________________________________
Email: ________________________________________________________________________
Membership Level Desired (Payment can be made by PayPal, cash, check, or M.O.):
_______ 1) Sustaining Member (individual only) ($25/month)
_______ 2a) Tent Club Individual ($50/month)
_______ 2b) Tent Club Family ($75/month)
_______ 3a) RV Club Individual ($75/month)
_______ 3b) RV Club Family ($110/month)
_______ 4a) Cabin Club Individual ($125/month)
_______ 4b) Cabin Club Family ($175/month)

Indemnity Agreement

I________________________________, and I ________________________________, having read and understood the rules of the Roxanna Club, which includes standards of conduct expected while at Roxanna, freely consent to these. By signing of this application and payment of my first month's membership dues, I agree to abide by the above rules. I also agree to hold harmless the owners of the site of Roxanna from all claims, actions, expenses and demands in respect to injury, loss or damage to my person or property, however caused, arising in connection with my participation even if the same may have been contributed to or occasioned by the negligence of the owners, the said body, or of any of its representatives.

_________________________________________________
Signature
_________________________________________________
Signature

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