NE65 Plus Runners Club Application Form

New England 65 Plus Runners Club

Encouraging Senior Runners to Participate in Running and Walking Events
INSTRUCTIONS:

Click your Payment Options: Online with Credit Card or Mail a Check

Please fill out the form below and click the SUBMIT button.

Questions or problems? Please contact David Theoharides, webadmin@ne65plus.org
Payment Options
You are paying by Check

Fill out the form below and Click the SUBMIT BUTTON when finished.
You will receive an email membership confirmation.

Please mail your check to and copy of your membership email to:

New England 65 Plus Runners Club
c/o Lisa DiBella, Treasurer
15 Oak Drive, North Hampton, NH 03862
Name

First NameLast Name
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Gender
Birth Date

MonthDayYear
Select SINGLET or T-SHIRT and size from the drop-down menu
Your membership includes a tech Singlet or T-Shirt
Where did you hear about us?

Other
Please write a brief summary of your running, walking, and/or track & field background
How can you help the Club?

Other
Paying by Check

Please Click the SUBMIT BUTTON when finished.
You will receive an email confirmation.

Please mail your check for $40
and copy of your email membership confirmation to:

New England 65 Plus Runners Club
c/o Lisa DiBella, Treasurer
15 Oak Drive, North Hampton, NH 03862
State
Please by Credit Card. Please enter payment information below
prevnext( X )
One Time Membership Fee
$40.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

New England 65 Plus Runners Club

Please by Credit Card. Please enter payment information below*

Payment Methods

Please by Credit Card. Please enter payment information below