Lodge Renewal Form

The Loyal Lodge of Ondessonk & Tekakwitha

Lodge Membership Renewal
Name*

First NameLast Name
Maiden Name
If applicable
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number:*

Area CodePhone Number
Year Inducted into Lodge
If you are renewing dues for more than one Lodge member who lives at the same address, please list their name(s) and year of induction below.

Lodge Dues & Sash

Lifetime Lodge Membership$250.00

Lodge Member Ages 10-24$10.00

Quantity

Lodge Member Ages 25+$20.00

Quantity

Lodge Sash$15.00

Quantity

Total $0.00

Acknowledgement of Potential Participant Inclusion in Publications: I hereby release to Camp Ondessonk, Diocese of Belleville and/or the American Camp Association the rights of my photograph, image, likeness and/or voice as recorded on video tape or film for the purpose of promotion, videos, yearbooks, website or publications. I hereby release any and all claims against Camp Ondessonk, Catholic Diocese of Belleville, its representatives, or officers arising in connection with the usage of my photo, likeness and/or voice. I acknowledge that this release is formal and final and understand that Camp Ondessonk, Catholic Diocese of Belleville, may proceed in reliance thereon. By checking the box below, I, the undersigned in this release, desire to assist in the work of Camp Ondessonk, Catholic Diocese of Belleville, by making my image, likeness, or voice available.
By checking here I, for myself and Minor(s), desire to assist in the work of Camp Ondessonk, Catholic Diocese of Belleville, by making my or Minor(s)’s image, likeness, or voice available.*

YesNo
Should be Empty: