Eastern Penn Mushroomers

APPLICATION FOR MEMBERSHIP 2012

NAME:  ___________________________________________________________________________________

ADDRESS:                                                                                  P.O. BOX: ________________

CITY:                                                                                STATE: ____  ZIP CODE: ___________________           

PHONE: ________________________________ E-mail Address:  _________________________________

DUES:  (Select one)

         Family Membership                                                        $20.00              

         Individual Membership                                                    $15.00

Make check payable to: Eastern Penn Mushroomers  

Please indicate your interests:

Learning Mushrooms                                                                 Eating Wild Mushrooms

Mushroom Walks                                                                      Mushroom Photography

Mushroom Art                                                                           Mushroom Dyeing

Cooking with Wild Mushrooms                                                   Cultivating Mushrooms

I hereby release the Eastern Penn Mushroomers and any officer or member thereof from any legal responsibility for injuries or accidents incurred during or as a result of any field trip, excursion, or meeting sponsored by the association.

APPLICANTS SIGNATURE:                                                                                            DATE: ___________