Membership Application Form
Last Name ________________________________ First Name_______________________ Middle Initial_____
Address _________________________________________________________________________________
City _______________________________________________ State___________ Zipcode_____________
Home Phone ___________________________________
Cell__________________________________________
Work Phone ___________________________________ Birth Date (under 25) _________________________
Email Address ____________________________________________________________________________
USCF ID _________________________ Expiration Date _______________
Club Membership Fees
New Members: ___ Six Months $40 ___ One year $75
Renewing Members: ___ Six Months $30 ___ One Year $65
___ Family Membership, first member full price, additional members 50% off each
___ K-12 Student Summer Memberships $25 (June 15 to Sept 15)
Membership fees do not include USCF tournament entry fees.
I have read and understand the Monmouth Chess School and Club Rules and Conditions and agree to abide by these rules and conditions. Non-adherence to this agreement may result in being asked to leave the club, with no refund of fees.
Signature _________________________________ Date _________________
Parent/Guardian Signature (for members under 18 years of age) _____________________________________
