Name of Primary Member

Name of Second Member

Address

City/State/Zip

Names and Ages of Children Residing in Household

Phone Number

Email Address

Emergency Contact

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By submitting this form and paying the nonrefundable $40 application fee, I hereby make application for membership in Pangborn Swim and Tennis Club and agree to comply with all rules and bylaws of said organization. I understand that my application is not complete and will not be considered until payment of the application fee.