Print this form. Fill it out and Mail it to the address listed below.
___Inividual Membership $40.00 ___Family Membership $45.00 ___Member Information Update Only
Member _____________________________________________Phone #_____________________
Alias ________________________________________________ SASS #_____________________
e-mail _______________________________________________ NRA #______________________
Street _______________________________________________ Apt. # or P.O. Box_____________
City _________________________________________________State ______ ZIP Code _________
Family Member _______________________________________Phone #_____________________
Alias ________________________________________________ SASS #_____________________
e-mail _______________________________________________ NRA #______________________
Street _______________________________________________ Apt. # or P.O. Box_____________
City _________________________________________________State ______ ZIP Code _________
Family Member ______________________________________Phone #_____________________
Alias ________________________________________________ SASS #_____________________
e-mail _______________________________________________ NRA #______________________
Street _______________________________________________ Apt. # or P.O. Box_____________
City _________________________________________________State ______ ZIP Code _________
I hereby apply for membership with the Pleasant Valley Renegades. If accepted as a member, I affirm
that I will abide by the rules, polices and by-laws established by the club, and that I will conduct myself at
all times in a manner that will not bring dishonor to the club, and that I fully support the purposes and
objectives of the club.
Member Signature __________________________________________Date___________________
Family Member or Guardian Signature ___________________________Date___________________
Family Member or Guardian Signature ___________________________Date___________________
Make Check payable to: Liz Gardner. Write in "Pleasant Valley Renegades" in the memo.
Mail this form and payment to: Liz Gardner, 2504 Raintree Dr, Clarksville, IN 47129
or bring it to the next club match.
Range Administration use only: Liability Waver(s) on File _______, Membership Approved ________
Pleasant Valley Renegades
Membership Application
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