Susquehanna Valley Whips and Wheels

 

                 2019

               SVWW Membership

                 Application Form 
    
Renewals requested by March 31, 2019




             

          Name(s):_______________________________________________________


          Address:_______________________________________________________

       

          Home Phone:___________________________________________________

          Cell Phone:_____________________________________________________

          E-Mail:_________________________________________________________


         Emergency contact Name_____________________Number_______________



        Circle Type:        

                 Individual($20)             Couple ($25)               Family ($30)

        Circle Membership status

                  New              or                Renewal

      Mail application and check payable to SVWW to

Amy Rankinen
130 middle Rd
Jersey Shore, Pa 17740

570-660-5085

amy.rankinen @gmail.com