Membership Form

NSS Information
NSS #		Other NSS Affiliation(s):
(New Members have 12 months to join the NSS) Membership
By which one grotto (or section) do you wish to be represented at the Congress of Grottos?.

Personal Information
First Name		Last Name
Address
City		State
ZIP		Country
Telephone		Fax
Email:		Birthdate (if under 18):

Emergency Information
Nearest Emergency Contact:
Name		Phone
2nd Nearest Emergency Contact:
Name		Phone

Known Allergies:
What color do you code your gear?

Membership Categories/Annual Fees (select all that apply)
	Regular(all privileges of membership)	$15.00
	Family (non-voting)	$ 2.00
	Arizona Regional Association (ARA) required dues	$ 2.00
If you have already made your ARA payment, please list which grotto you have paid ARA dues through and uncheck ARA box

I, the undersigned, being desirous of caving, exploring, or otherwise entering upon and under land and premises, and being aware of the risks and hazards inherent in caving and having elected voluntarily to participate, do hereby release fellow cavers and all persons, unincorporated associations or corporations from any and all liability either in law or equity for any injury, death or damage which might ensue. This release shall bind myself, my heirs and/or representatives.

I desire to be admitted as a member of the Northern Arizona Grotto of the National Speleological Society. I will uphold the Constitution, Bylaws and policies of the National Speleological Society and the Northern Arizona Grotto.

I have read, understand, agree with this application and the above NSS Policy for Cave Conservation

YES


	Please, once form is submitted send your check to: Northern Arizona Grotto of the National Speleological Society c/o Christine Zimmer 7840 E. Manley Dr. Prescott Valley, AZ 86314 voice/fax: 520/775-2390 Membership will become effective once payment is received

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