MEMBERSHIP APPLICATION

1. HUSBAND WIFE

Name Name

(Last, First) (Last, First )

Occupation Occupation

Employer Employer

Home Address

(Street) (City, State Zip)

Phone E-Mail Address

2. CHILDREN

NAME SEX DATE OF BIRTH

3. EMERGENCY CONTACTS

NAME PHONE RELATIONSHIP

4. I FOUND OUT ABOUT BROOKSIDE FROM: A Member Family (complete Sponsoring Family below)

Advertising (Please Describe) ____________________

Web Site

Other (Please Describe)

5. SPONSORING FAMILY (if applicable)

NAME PHONE

ADDRESS

6. REFERENCES (Please list at least 2, preferably with minimum 2 years membership)

NAME PHONE

ADDRESS

NAME PHONE

ADDRESS

NAME PHONE

ADDRESS

7. I do hereby accept the conditions for “Associate Life Membership” as listed, should my application be

approved by the Board of Trustees. I accept their decision as final with no recourse to law.

DATE SIGNATURE

OFFICE USE ONLY

Date Application Received Date Membership Approved

Approved By

Check Received Check Number

2/2004