RVSA MEMBERSHIP FORM

New member � or Membership renewal �

Membership Type: Individual � or Couple �

PLEASE PRINT

Name 1 ___________ ___ _______________ Birthday ______

First MI Last M/D

Name 2 ___________ ___ _______________ Birthday ______

First MI Last M/D

Address ___________________________

City ___________ State ____ Zip __________

Phone #1 ___________________ Phone #2 __________________

Email #1 ____________________________ Email #2 ________________________________

Membership Fees

New/Delinquent Member: Individual $25 Couple $45

Renewal Individual $20 Couple $35

Make Checks payable to RVSA

Mail to: RVSA

C/O Suzanne or Mike Bumbard

3941 Genoa St .

Cherry Valley, IL 61016

Phone 815-670 7585 or 815-289-4924

Reciept No. __________ Cash/Check No. _________