GLCHA 

2012 MEMBERSHIP APPLICATION

____ Individual (new/renewal) $30

____Family (new/renewal) $40

              *Includes spouse and children 18 years & under as of January 1

____Youth (new/renewal) $15

               *18 years & under as of January 1

Name___________________________________________NCHA #_______________________

                   Non-Pro ( )Y ( )N                                        SS#____________________________

Name of Spouse___________________________________NCHA #_______________________

                   Non-Pro ( )Y ( )N                                         SS #___________________________

Name of Youth(s)

1._____________________________________________NCHA #_______________________

                   Non-Pro ( )Y ( )N                                       SS #___________________________

2._____________________________________________NCHA #_______________________

             Non-Pro ( )Y ( )N                                             SS #___________________________

3._____________________________________________NCHA #_______________________

                 Non-Pro ( )Y ( )N                                         SS #___________________________

Address_____________________________________________________________________________

City____________________________________State_________Zip___________________________

Phone__________________________________Alt Phone__________________________________

E-mail Address(to receive newsletter/updates)________________________________

PLEASE MAKE CHECKS PAYABLE TO: GLCHA

RETURN TO:

GLCHA Membership

Crystal DeWitt

4025 Hollow Corners Rd

Dryden, MI 48428

Any questions, call Crystal (586)295-2733