Single Membership Dues $50.00 Family Membership Dues $65.00
Single Membership _____ Family Membership: _____
NEW MEMBER ONE-TIME APPLICATION FEE: $25.00
LAPSED MEMBERSHIP REINSTATEMENT FEE (2 yrs. or more lapsed membership): $25.00
THIS APPLICATION IS FOR: NEW MEMBER _____ RENEWAL _____ REINSTATEMENT______LIFETIME _____
A family membership includes up to 2 heads of household & only dependent children under the age of 18. You must provide names of dependent children on back of form along with DOB for each. All persons age 18 or over (including children of members) must have their own memberships.
Number of cards needed ___ Name(s) on card__________________________________________________________
NOTE: The annual membership period runs from the Annual Club Meeting in January of the current year to the Annual Club Meeting in January of the next year.
LIABILITY RELEASE:As a member of the Boothbay Region Fish and Game Association, Inc., I agree to waive and release from liability and agree to hold harmless the following: The Boothbay Region Fish and Game Association, Inc., its elected officers and representatives, for any and all damages of any kind or nature to my person and property arising out of or resulting from my direct or indirect participation in any and all Association activities or exercises of membership or privileges. I attest that I will not use the club firing ranges until I have successfully completed a formal Range Orientation Session. Furthermore, I understand that persons under the age of 18, including my dependent children/family members, are prohibited from using the firing ranges unless accompanied and closely supervised by a parent or other BRF&GA member in good standing over the age of 21 who has completed a Range Orientation. I agree to abide by all BRF&GA bylaws, rules and regulations (visit www.brfga.com). Finally, I state that I have read all of the above and have kept a copy for my own information.