This Membership Application is for New Membership Renewal (Please select one)

Name

Address:

City:         State:     Zip Code:

Occupation:   

Email Address:

Home Phone:         Work Phone:

Birth Month and Day:

Your Signature:____________________  (Must be 21 years of age)   

Please make  checks  payable to: Treasurer ,Roanoke Valley Shag Club, Inc.

Mail to: Roanoke Valley Shag Club - P.O. Box20723 - Roanoke, VA 24018