Date of Birth:
Emergency Contact - Optional Information
Name of Relative not
residing with you:
Membership Fee &
Yearly membership is $25.00 per year - due March 1st. Dues are
$12.50 after September 1st. Associate Membership Fee: Yearly associate membership is
$10.00 per year - due March 1st. Dues are $5.00 after September
be held confidential by the officers of Empire Z. Your personal
information will not be sold or revealed to anyone without your
specific permission. I hereby state the above information to be true.
Release of Liability I hereby
release Empire Z, its officers and members, from any liability due
to accident, injury, theft, or any other reason while attending or
participating in any and all Empire Z events and/or functions.
Membership application is not complete until you have indicated a
"Yes" answer to understanding this release and entering a date.
I understand and
agree to the above release of liability.
Must Select "Yes" or "No" Date:
Pay your dues On-Line with your PayPal
account. Log-in to your PayPal
account and make payment
Indicate in the Remarks section of PayPal that you are making a payment
for yearly dues. Be sure to complete and submit this Application so
we know who to apply the payment to. You are not a member until
your dues are received in our PayPal account.
You will view a
before final form submission.
Click on the "Submit"
button at the Top of the preview
if all entries are correct.