Date: ___________________
                      
1. Name _____________________    2. Sex _________________

3. Date of Birth _____/______/______    
4. Mailing Address:
Street Number: _____________________ Apt # _____________

City:  ____________________    State /Zip _______________


5. Telephone Numbers:  Area Code (     ) ___________ Home
                       Area Code (     ) ___________ Work
6. E-mail Address:   ___________________________________
7. Occupation: __________________________________________
8. Interests:
[  ] Hiking    [  ] Camping     [  ] Biking   
[  ] Canoeing  [  ] Backpacking [  ] Jogging
[  ] Other: (please specify):
9. Volunteers work that you are interested:
[  ] Trip Leader           [ ] Newsletter Publishing
[  ] Bookkeeping           [ ] Public Relation 
[  ] Web site maintenance  [ ] None
10. Do you have a car for traveling?   [ ] Yes    [ ] No
11. Do you have the following outdoor equipment?
[  ] Hiking boots      [ ] Day pack   [  ] Backpack
[  ] Wind/Rain jacket  [ ] Bike       [  ] Sleeping bag
[  ] Compass           [ ] Tent      
12. Please check your membership type:
[  ] 1 Year Individual   Fee: $12.00
[  ] 1 Year Family*      Fee: $20.00
[  ] 5 Year Individual   Fee: $50.00
[  ] 5 Year Family*      Fee: $90.00

Note:

* Family membership includes parents and their child/children whose ago is/are under 18 only.

All memberships are subject to the approval of the Board of the Club. The CMCNY does not discriminate because of race, creed, sex or national origin Members agree to abide by the Bylaws of the Club and the instructions of the trip leaders. Members agree to honor Club policy.

Payment of dues constitutes agreement of those signed below with the policies of the Chinese Mountain Club of New York including the following LIABILITY WAIVER STATEMENT, which MUST be signed by all persons age 18 and older who wish to belong to the CMCNY under this application. If this is an application for JUNIOR membership, a parent or guardian as well as the applicant MUST sign.

“I am (We are) aware of the risk inherent in outdoor activities. Therefore I (we) will be responsible for my (our) own well-being while participating in the activities of the CMCNY, and while traveling to and from these activities. I (We) agree that the CMCNY, its officers, representatives and trip leaders shall not be liable for any injury, loss or damage to my (our) person(s) or property, direct or consequential, arising out of the Club. If I am a parent or guardian (if we are parents or guardians in a family membership, I (we) agree to assume this same responsibility for my (our) minor children”


__________________________________________
Participant’s Signature and Date

__________________________________________
Participant’s Signature and Date

PLEASE MAKE CHECK PAYABLE TO:
Chinese Mountain Club of New York