Hi-ROLLERS M.C. ASSOCIATE MEMBERSHIP

**PLEASE PRINT**

DATE:______________

Name:_______________________________________

Name:_______________________________________

*(FAMILY MEMBERSHIP PLEASE LIST BOTH NAMES)*

ADDRESS:_________________________________________

CITY:________________STATE:_____________ZIP:________

PHONE:(_______)_______________BIRTH DATE:_______________

BIRTH DATE:_______________

E-MAIL:___________________________________________________

ASSOCIATE MEMBERSHIP FEES:

SINGLE: $10.00 PER-YEAR_______(ONE PATCH)

FAMILY:$15.00 PER-YEAR_______(TWO PATCHES)

OTHER CLUB AFFILIATIONS:_________________________________