Island Falls Free-Wheelers Membership Form

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):___________________________

$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 Sandy Rockwell
463-2704, Jim Slauenwhite 463-2437 or John Alexander 521-0134.

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