ISLAND FALLS FREE-WHEELERS A.T.V. CLUB
                                    PO BOX 45
                             ISLAND FALLS, ME 04747
                     EMAIL: islandfallsfreewheelers@hotmail.com

                                                                                    _____ $20.00   Primary Membership 
                                                                                    _____ $10.00  Associate Membership
                                                                             
                                                                                   _____ NEW _____RENEWAL
Please print clearly

PRIMARY CLUB: _________________________________________________

ASSOCIATE CLUB:_______________________________________________

NAME:________________________________________D.O.B.:____________ PHONE:(____)_____-______

MAILING ADDRESS:________________________________ TOWN:_________________________________

STATE/ZIP:_____________________________________ SPOUSE:___________________________________

CHILDREN(under 18):________________________ Member of MSA: YES or NO
                                                                      (Maine Snowmobile Association)

EMAIL(for newsletter):___________________________________ # of wheelers:____________________

$2,000 Accidental Death & Dismemberment Insurance for the member, spouse and children under 18
living in the same household.
AREAS OF INTEREST: CIRCLE ALL THAT APPLY
TRAIL WORK EQUIPMENT LANDOWNER RELATIONS SAFETY TRAINING OFFICERS
SEARCH & RESCUE BOARDS/COMMITTEES FUNDRAISING ACTIVITIES/EVENTS
HELP WHERE NEEDED

I understand that by signing this form, my membership can be discontinued at any time if the club or
its officers have reason to believe that I or a member of my family operates an ATV irresponsibly so
that it endangers the landowner/club relationship or if it is believed that the operator could cause
harm to another individual. My membership fee is non-refundable and it is intended to be used
to support the club as a whole. I agree to hold harmless the Island Falls Free-Wheelers A.T.V. Club
from all liabilities resulting from my involvement with the club. Any questions call Lloyd Phillips
538-8146.

Signature:__________________________________ Date: ________________________________
Please make checks payable to: Island Falls Free-Wheelers A.T.V. Club, PO Box 45, Island Falls, Me 04747
           
                            TREAD LIGHTLY AND RIDE SAFE ON PUBLIC AND PRIVATE LANDS