North Country Club of the Deaf
Membership Form
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Required to Fill out* (PRINT CLEARLY)
Name*_________________________________________________
Street*________________________________________________
City*_____________________________ State* ______ Zip Code*_________
Telephone*________________________ [__]TTY [__] Videophone [__] Voice [__] Text/Pager
Fax __________________________________
Email _____________________________________________________
____Check here for Address Correction
Select all apply:
[__] Deaf [__] Hard of Hearing [__] Hearing [__] Interpreter [__] Have Deaf Children [__] CODA
____ Active - $10.00 (Deaf) - 1 Year
____ Associate - $10.00 (Hearing) - 1 Year
Make Money Order payable to North Country Club of the Deaf
(Sorry, We do not accept any personal check )
Print & mail it with a Money Order to:
(NO PERSONAL CHECK)
North Country Club of the Deaf
Membership
PO Box 164
Watertown, NY 13601-0164
For more information, Contact membership Secretary, Kathy Ferritto - nccd13601@yahoo.com
_________________________________________________________________________________
New Membership Application Form
Or
Renewal Membership 2012
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OFFICIAL USE ONLY
Rec'd Date ______________ Cash________ Money Order __________
Member's Expiration Date_______________________________
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