2023 West Island Improvement Association Membership Form Age___ Member Names: (Please Print) 181067 68+ Under 18 $35_| | $20 30 $35_] [$20 $0 $35_| | $20 $0__| Emer Total $35 | | $20 $0 Annual Membership Fees: Al! Fees are per member Member Age 18 to 67: $35.00 ‘Age 68 and over: $20.00 Child under 18: Free West Island Friend Names: (Please Print) Friends of West Island category are non-voting, non- residents who will be able to attend Member Only events. This option is only available to non residents. Ht L$20_} $20, $20, f you would like to make an additional contribution, please indicate the amount here S. and include it in your cheek total. Thank ou for support Improvement v Contact Information: (Please Print) Mailing Address: Island Address (if different): see Phone: _ Email: (Note; Your email address will not be shared with any other entity) Would you also like 10 receive Association information via email? YES___ NO__ Please mail this form and check (made payable to WII) to: WIIA —41 Causeway Road, Faithaven, MA 02719 E Mail — westisland2019@gmail.com Feel free to call me with any questions. Dave Roberts, WIIA Membership Clerk @ 603-218-9435 Signature: Date Check or Cash Amount: _ In sing tis form, acknowledge hat Ian those in ay West sland tmpeovementAssoraton membership, wil indemnify and iol harlss the West sland Iimpovernent Associton fom any wd ail ams, ncuding bol ny, ropety damage, and abies, arising ou of te Indennitor' aves upon any West [sland provement Assoistion Property