( ) Single ... $27 ( ) Family ... $45

Last Name ________________________________________________

First Name _____________________Spouse_____________________

Address ___________________________________________________

City _____________________________ State ________ Zip _________

Home Phone ___________________ Work Phone _________________

Birth date Self ____/____ Spouse ____/____

(month and day only)

Make all checks payable to ERIE SHORE SKI CLUB and return the signed completed form and dues payment to:

Sandra Lopatka

10248 Prospect

Strongsville, Ohio   44136

Direct any questions regarding membership

Sandy Lopatka at 440.572.3245 or

E-Mail  Mike Linner at mlinner@aol.com
Please make sure to include ESSC in the subject field.

The Erie Shore Ski Club, Inc. shall not be liable for bodily injury, property damage, loss of personal property , delays or inconveniences sustained by any member or participant in any activity or on any trip arranged for in whole or part by the club. It is a condition of membership in the club that any individual shall be deemed to have accepted as consideration this limitation of liability by joining the club and/or attending such activity.

_____________________________ / ____________________________

Signature(s)

Date ____/____/____