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 preceding the information you DO NOT
want published in the annual Membership Roster.                   

MAIL TO:  Chemeketan Membership Secretary,  PO Box 864,  Salem OR  97308

NAME:_____________________________________________________     
                                                                                    
 ADDRESS:__________________________________________________    

CITY:__________________STATE:_____ ZIPCODE:___________________

BIRTH DATE (mm/dd/yr):__/__/__(required if under age 18)

 PHONE: (____)__________  E-MAIL __________________________

Send the Monthly Bulletin:     by surface mail, or     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.
  Adult: (18 and over) $31 ($12 Bulletin subscription* plus $14 dues plus $5 application fee)
   Junior: (under 18) $20 ($12 Bulletin subscription* plus $3 dues plus $5 application fee)
* $12 Bulletin subscription fee is for one monthly Bulletin mailed to one household address and is paid once per household address.