Address    City ST Zip

Cell Phone Home Phone Work Phone

Email Birth Date DL# ST

Name of spouse (if not a Family Membership)

Names of children under 21 with year of birth (children 21 AND OVER are GUESTS):

Emergency Contact Phone

FOR FAMILY MEMBERSHIP ONLY:

Name of 2nd adult in Family Membership DOB

Cell Phone Work Phone Email

SERVICE TO PSC - Any particular skills, professional abilities, talents or interest you can help with maintaining the lodge, club operations, membership, social, skiing, newsletter or other activities, etc:

REGULAR MEMBERSHIP $150 (one adult with or without children under 21) + one time Initiation Fee of $100 = $250 Total
FAMILY MEMBERSHIP $200 (two adults with or without children under 21) + one time Initiation Fee of $100 = $300 Total

Please submit membership form and signed Liability Release to Bill Cohen, Membership Chair, protouch@comcast.net or MAIL TO Bill Cohen 5669 Snell Ave #340 San Jose, CA 95123 along with a check made out to Peninsula Ski Club. Any questions or for online payment, contact Bill at 408-772-8157.