Date: ____________________    Amount Paid: _______________

Primary member name: ______________________________________________

Address: __________________________________________________________

City: _____________________________________________________________

State: _________________________   Zip Code: ______________________

Home Phone: _____________________   Work Phone: ___________________

Email: ____________________________________________________________

AMA #: _____________ (required)  Date of Birth (Sr/Jr): ___________

RC Channels of Operation: _________________________________________

Skill Level:  Beginner ____     Intermediate ____     Advanced ____

Type of membership:

    Junior (age 17 and below) ____           Adult individual ____

    Senior Citizen (age 65 and above) ____   Family ____

Family members: ___________________________________________________

___________________________________________________________________


I have included an additional $3.00 for each name badge: ____
(indicate badge names)

I prefer to receive my newsletter via email: ____

I agree to accept and abide by the AMA and Forest Preserve District
of Dupage County rules and regulations concerning the handling and
flying of my model aircraft.



_________________________________________
Signature