Carolina Bassers of Harnett County Youth Division NC State Youth Chapter 4130

	Members Initials
I hereby agree that I have read and understand the rules and regulations of this club.
I understand that the club or club members are not liable for any accidents or property loss.
I understand that if I fail to comply with the rules and regulations of the club that I will be either suspended or expelled.

Name: ____________________________	Date: ____________________________
Address: ____________________________	Home Phone: (_____)___________________
____________________________	Age: _________________________________
____________________________	DOB: _________________________________
Signature of	Guardian: ____________________________

I am applying for Jr. Membership.

__________________________________

Signature

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--== Receipt – Carolina Bassers of Harnett County yearly dues ==--

__$25.00__	____________________________________
Dues Paid	Signature of Treasurer or Secretary