Keoneula Running Club Membership Form

Date____________ New Member________

Parent/Household Information:

Name____________________________________________________________________________

Street___________________________________________________ Apt._______

City_______________________________________ State_______ Zip________

Phone_______________________ Cell__________________

E-mail address_____________________________________________

Keoneula Student Information:

1)Name ____________________________________________ Date of Birth ___/____/____

Grade ______ Classroom ________ A+ yes no

t-shirt size: child or adult s m l xl Male Female

2) Name ____________________________________________ Date of Birth ___/____/____

Grade ______ Classroom ________ A+ yes no

t-shirt size: child or adult s m l xl Male Female

3) Name ____________________________________________ Date of Birth ___/____/____

Grade ______ Classroom ________ A+ yes no

t-shirt size: child or adult s m l xl Male Female

___________________________________________________________________________

Parent Signature/ Date

___________________________________________________________________________

Please print parent’s name

Please indicate type of membership below. Fees are as follows:

 _______$30/year for individual membership

 _______$10/year for each additional child in the same household