MEMBERSHIP APPLICATION

Name:__________________________________________________________________

Address:________________________________________________________________

CITY:__________________________________ STATE: _________ ZIP:____________

PHONE: (______)________________________________________


E-Mail Address:___________________________________________________

Enclosed is my contribution / dues for 1 year at $10.00_______
OR
Enclosed is my contribution / dues for 3 years at $25.00________
OR
Enclosed is my contribution / dues for Lifetime at $100.00________


Optional:
Do you have scouting affliation?

YES:______ NO:______

If so: Unit Type:_________ Number: _______ Position: ____________________

Council:_______________________________ District:______________________



Do you have any Scouting memorabilia you would like to donate to the association?: _________

PRINT out this page and mail your check payable to:

Jack Kohler Campership Association
c/o Morgenstern, 64-34 99th St., Apt 2-A, Rego Park, NY 11374

"HELP US MAKE EVERY SCOUT A CAMPER!"