Associate Membership Application
| Name: | __________________________________________________ |
| Address: | __________________________________________________ |
| City: | __________________________________________________ |
| State & Zip: | __________________________________________________ |
| Phone: | __________________________________________________ |
| E-mail: | __________________________________________________ |
| Club Affiliation: | __________________________________________________ |
| Birthday: | __________________________________________________ |
| Today's Date: | __________________________________________________ |
Mail the following with your application:
- Reason you would like to support the KC Pioneers
- A photo of self
- A check for $15 drawn on a U.S. bank and payable in U.S. funds to "KC Pioneers"
_____ Please check if you do not want us to use your full name in our newsletter and web-site. ( We will use your first name and initial)
_____ Please check if you do not want us to use your photo in our newsletter and web-site.
| For KC Pioneer Use Only | |
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| Date | |