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Address: 

City:  , State:   , Zip: 

Email:    Birth Date: 

Day Phone:    Evening Phone: 

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Check one of the following:
  Open membership dues $25.00 ($5.00 discount if paid before March 1st)

  Junior and 2nd family member dues $10.00 (no discount for early payment)
                      Dues half price after September 1.

Amount paid:   Please make out check to Balsa Busters and mail to:

Rich Hook
325 W. Long Ave.
DuBois, PA  15801

"I will abide by all club rules"

Signature if printed out and mailed in: 

 ____________________________________  

Date: