Membership Application

Please Print All Information

Last Name: _______________ Pilot: _______ Co-Pilot: _______

Birthdates Pilot: _______ Co Pilot: _______ BOA# _______

Address: __________________ City: __________ State: __ Zip: ______

Phone# (___) ____ -_____ Cell # (___) ____ - _____ Cell # (___) ____ -_____

Emergency Contact; __________________ Phone # (___) ____ - _____

Bounder Data: _____ Year _____ Length   Gas Or Diesel

Email Address: ________________ @ ________
Email Address: ________________ @ ________

I/We accept and will abide by the by-laws of the Keystone Kangaroos Chapter and are
presently members in good standing with Bounders Of America
Signed: ____________________ Date: ______________

Payment: Application Fee $25.00 ($10.00 initiation fee, $15.00 annual dues)
Annual dues payable in January of each year
Mail completed application/check made out to Keystone Kangaroos
Send to: Sara Shank Treasurer 756 Heather Ridge, Manheim, Pa. 17545