BLACK HILLS CLIMBERS COALITION

 MEMBERSHIP APPLICATION

Please fill out and return with dues to:

Jim Slichter c/o BHCC  

24102 Jacob Maca Drive

Hill City, SD 57745

Copies of the By-Laws and Standard Rules of Operations

can be obtained from any Club Officer

________________________________________________________________________

This application is for an (check one) ______ individual membership @ $10.00 per year or for a ______ family membership @ $20.00 per year. 

All memberships expire on the first of August each year.

Name: ____________________________________________________

Address: __________________________________________________

City/State & Zip____________________________________________

Home Phone: ______________________________________________

Work Phone: _______________________________________________

E-Mail Address to Receive Newsletters___________________________

Climbing Level:   (Circle One)  5.0-5.7   5.7-5.10  5.10-5.12 5.12-Over  

For Family Membership, please list other family members:

#1__________________________________________________________________

            Name                                                   Relationship       Age         Skill Level

#2__________________________________________________________________

            Name                                                   Relationship       Age         Skill Level

#3__________________________________________________________________

            Name                                                   Relationship       Age         Skill Level

#4__________________________________________________________________

            Name                                                   Relationship       Age         Skill Level

#5__________________________________________________________________

            Name                                                   Relationship       Age         Skill Level

#6__________________________________________________________________

            Name                                                   Relationship       Age         Skill Level

I certify that I am twenty-one years (21) years of age or older and agree to abide by the By-Laws and Standard Rules of Operation of the Black Hills Climber’s Coalition.

____________________________                            ____________________________

For Black Hills Climber’s Coalition use only

Date Received____________         Amount of Dues Received___________