Membership Registration Form
Please print, complete, and return this form with your check payable to “White Plains Ski Club”
to Patty DeCuffa, 125 Willis Avenue, Hawthorne, NY 10532.
City: _______________________________ State: _________________ Zip: _______________
Home Ph: __________________ Cell Ph1: _________________ Cell Ph2: ____________________
Email1: ______________________________ Email2: __________________________________
Please identify membership type (Single, Single Family, or Family) ________________________
Single Family and Family members, please list all children's names and ages: ______________
Please circle appropriate dues according to membership type. Applies to all provisional and full members.
Advance Trip Deposits:
Please circle appropriate advance trip deposit fees according to membership type. Applies to all provisional and full members.
Initiation fee applies only to new members upon formal acceptance and returning members after a year or more absence.
Work weekend penalty applies only to full memberswho did not complete a work weekend during the proceeding summer or fall season. It does not apply to first year Provisionals.
Late Registration Fee:
Late Registration Fee applies only to provisional or full members who are paying after December 1st.
Please total dues, advance trip deposit, and any applicable additional fees.
Check #: __________________ Total Amount Due: $ _____________________
Signature: ________________________________________ Date: ______________________
Please direct any questions to Patty at firstname.lastname@example.org. Thank you!