Membership Application
Space Cost Paddlers
An American Canoe Association Affiliated Club

Date:______________________________

Applicant

Name__________________________________________________ 

Age_____ Phone (_____) _______________

Address____________________________________ City_____________________ State____ ZIP____________

Emergency Contact______________________ Relation__________________ Phone (_____) ________________

Type of Membership

Single             Family            (Family is father and/or mother and children under age 18 at the same address)

			Names of family members (Other than applicant):  1. _____________________Age _____
			2. ______________________ Age______      3. _________________________ Age_____
			4. ______________________ Age ______     5. _________________________ Age_____

Fees :    Single - $25 per year    Family - $30 per year    (Make checks payable to Space Coast Paddlers)

Membership includes voting privileges, participation if club activities, SCP monthly newsletter, and American Canoe Association membership, including Paddler magazine and ACA liability insurance for SCP activities.

Mail this application with your payment for fees and ACA Liability Insurance Program form to:
Space Coast Paddlers, P.O. Box 360193, Melbourne, FL32936

SCP Release of Liability

There are risks, known and unknown, associated with entering in and upon water in small watercraft.  Each of the undersigned, for him/her personal representatives, heirs, or next of kin, agrees that any individual officers, activity leaders, or representatives of Space Coast Paddlers shall be held harmless and free from blame for any and all claims for bodily injury, sickness, disease, death, or personal injury or damage to property or loss of use of property resulting from such claims.

1.	Printed Name_________________________________________________________________________________

Signature _______________________________________________Date __________________________

2.	Printed Name (2nd family adult, if applicable)___________________________________________________

Signature _______________________________________________Date __________________________

Parent or guardian must sign if applicant is under age 18:

     Printed name of parent or guardian ______________________________ Relationship__________________

    Signature _______________________________________________________________________________