Island Mountain Ramblers Membership Form

Membership Registration Form
Membership Type: *

Single Membership ($34 CAD) Family Membership ($55 CAD) Associate, ACCVI ($21 CAD) Associate, FMCBC ($13 CAD) Student ($20 CAD)
FMCBC Parent Club:
School Name
Applicant's Name *

First Name Last Name

Address *

Applicant's Phone Number *

Area Code Phone Number
E-mail *
Family Members

Family memberships allow for a maximum of four members. If your family has more than 4 members over the age of 10 years of age, please complete additional applications using "student" as the membership type.
1st *

First Name Middle Name Last Name
Email
example@example.com
Date of Birth

- Month - Day Year
Date Date Picker Icon
2nd

First Name Middle Name Last Name
Email
example@example.com
Date

- Month - Day Year
Date Date Picker Icon
3rd

First Name Middle Name Last Name
Email
example@example.com
Date

- Month - Day Year
Date Date Picker Icon
4th

First Name Middle Name Last Name
Email
example@example.com
Date

- Month - Day Year
Date Date Picker Icon
Emergency Contact
Contact Name *

First Name Last Name
Contact Number *

Area Code Phone Number
Consent
I understand that my name, membership status, and date I signed the waiver will be shared with club leaders. *

I undersand
Should be Empty:

Membership Registration Form