Jefco Aeromod’lers RC Club #176 Renewal or New Membership Application Membership is valid from January 1st – December 31st Member Information – Primary (* Required entry) Membership_Registration If you are human, leave this field blank. First Name * Last Name * Email Address * (required to receive electronic newsletters) Confirm Email Address * Confirm Email Phone number * (Primary number) Optional 2nd phone number (Cell or other) Birthday Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month Day Day Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip Zip *AMA membership is required for club membership. If you have not applied for AMA membership, you can do so online at www.modelaircraft.org. You will receive a temporary card until your official AMA number/card is issued. If you have applied for AMA membership and have not yet received your AMA number, write “In Progress” in the box below. Membership Types * New (includes $25 club initiation fee) $75 Adult Member (prorated after July 1 = $50) - (see note 1) $40 Junior Member - under 19 yrs of age (see note 1) $40 Associate Members -out of state (see note 2) Renewal $50 Adult Member (prorated after July 1 = $25) (see note 1) $15 Junior Member - under 19 yrs of age (see note 1) $15 Associate Member - out of state (see note 2) Life $750 Life Membership (see note 1) AMA Number * Note 1: All club privileges for member and family. One vote per member. Note 2: No voting privileges Additional Member information - Optional Check box to add an additional Family member - $15 First Name (Additional member) Last Name (Additional member) Email (Additional member) (required to receive electronic newsletters) Confirm Email (Additional member) Confirm Email AMA Number (Additional member) READ AND CLICK Below - * I hereby request membership in the Jefco Aeromod’lers RC Club #176. READ AND CLICK Below - * I have read and understand the Field Safety Operations Guidelines as outlined in the Field Safety & Operations Manual (available at the flying field, club meetings, website or any board member). FIELD SAFETY & OPERATIONS MANUAL > READ AND CLICK Below - * I understand that I must have current Academy of Model Aeronautics (AMA) membership for approved membership in the Jefco Aeromod’lers RC Club. If I am not already an AMA member, I will immediately apply (www.modelaircraft.org). I understand that AMA membership includes valuable liability insurance coverage for accidents involving model airplanes. READ AND CLICK Below - * I agree to fully display my club name badge and AMA card on my body while at the flying field. READ AND CLICK Below - * I agree by checking and signing with my initials below, I acknowledge I have read and will abide by the flying field rules. Flying Field Rules> Please enter your initials below * reCAPTCHA Total $ An email will be sent to you confirming your membership and receipt of your fees. If you do not receive a confirmation email, your membership application was not completed.