Beulah Recreation Association, Inc. P.O. Box 37324 North Chesterfield, Virginia 23234 New Membership Registration 2015 This form must be completed and signed prior to processing your membership. Please read each membership category below and mark which type applies to you. There is a one time Registration Fee of $200 for new members. If you have questions, please contact Mary Anne Huband, Membership Secretary at 804-464-1570. __________ Family (Head of household and spouse/domestic partner, if any, with all dependent children who can be claimed as an exemption on their Federal Income Taxes) $385 . __________ Limited Family (one adult and one single dependent child) $310 . __________ Single (one individual 18 years or older) $235 . __________ Couples (one adult and one adult spouse/domestic partner residing at the same address with no dependent children) $347 . ___________ One Time Registration Fee of $200 (must be paid in full). Member Name:________________________________________________ DOB:________________ Age:_______________ Spouse:_______________________________________________ DOB:________________ Age:_______________ Address:___________________________________________________________ Home Phone:________________ City: _________________________________________ State: ______________________ Zip: _________________ Email: _______________________________________________________ Communications may be sent via email (if you require U.S. Postal service in lieu of email please provide written request). Dependent name:__________________________________Relationship to applicant:___________ DOB:__________ Dependent name:__________________________________Relationship to applicant:___________ DOB:__________ Dependent name:__________________________________Relationship to applicant:___________ DOB:__________ Dependent name:__________________________________Relationship to applicant:___________ DOB:__________ Emergency Conact:_____________________________ Relationship:__________________ Phone:________________ Member Signature:____________________________________________________ (REQUIRED) Return this completed form with payment to: Attn Mary Anne Huband Beulah Recreation Association, Inc. PO Box 37324 North Chesterfield VA 23234 A $45 processing fee will be assessed on checks returned by your financial institution. Date Received: __________________Received By: _______Member #_____________ Membership Dues Paid: ___________Joining Fee Paid: __________Check #: _______Cash:_______