Membership Application Form
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I hereby apply for membership in the CHEMEKETANS.
I certify that I have participated in two qualifying trips.

Check the box o preceding the information you DO NOT
want published in the annual Membership Roster.                   
                                                                                                   MAIL TO:

o NAME:___________________________________        Chemeketan Membership Sec'y
                                                                                                   PO Box 864
o ADDRESS:________________________________       Salem OR 97308

   CITY:_________STATE:___ ZIPCODE:________BIRTH DATE (mm/dd/yr):__/__/__(required if under age 18)

o    PHONE: (____)__________ o E-MAIL __________________________________________

Send the Monthly Bulletin:     o by surface mail       o by Email (arrives one week earlier)

    Name of Qualifying Trip            Date of Trip                     Endorsement of Trip Leader

#1: ____________________     _____/_____/______   ______________________________________

#2: ____________________     _____/_____/______   ______________________________________

                            RELEASE FROM LIABILITY AND ASSUMPTION OF RISK
I am aware that Chemeketan activities including, but not limited to, hiking, backpacking, mountain climbing, skiing, bicycling and canoeing are potentially dangerous, that accidents can happen and that illness can occur in remote places.

In consideration of being permitted to join and participate in Chemeketan activities, I do for myself, my heirs, legal representatives, and assigns (or, if applicable, as a parent or legal guardian of a minor), assume all risks associated with such activities and traveling to or from such activities, and release and discharge the Chemeketans, their officers and agents from all liability for any and all loss, damage, or claim on account of property damage, death or bodily injury to me, my minor child, or minor child for whom I am legal guardian, caused by the act or failure to act of the Chemeketans, their officers and agents.

I agree to pay for my own medical and/or rescue expenses, whether or not authorized by me, in the event of accident or illness.  I have read and understand this release and sign it voluntarily.

______________________________________     ________________________________________
Signature of Applicant                                  Date                          Signature of Parent or Guardian                 Date
                                                                                                                                                       (if applicant is under 18 years of age)
    Date elected into membership: (Chemeketan use only)___/___/___

Membership Fees: Application for membership must be accompanied by the appropriate fee. Applications accepted into membership between October 1 and December 31 will cover dues for the current and following calendar year.
  w Adult: (18 and over) $31 ($12 household newsletter subscription fee* plus $14 dues plus $5 application fee)
   w Junior: (under 18) $20 ($12 household newsletter subscription fee* plus $3 dues plus $5 application fee)
* $12 household newsletter subscription fee is for one monthly Bulletin mailed to one household address and should only be paid once per household address.
                                                                                               revised  3/1/2007