Swingin' Singles Membership Application
To complete the application, print clearly and return it, along with applicable fees, at a dance or mail to:
Karen Juarez, 6600 Mullen Road, Shawnee, KS 66216-2169 
Phone: 913-268-4180   Cell: 913-660-3948

Annual Renewals are due September 1
New Applicant          
 Renewal           
                  Today's  Date:   
        Personal Information:   List in Directory ?     (Directories are distributed to club members only)
 Name:                   Birth Date   (MM / DD)    
 Address:         
 City:                    St:     Zip+4: 
 Home Phone:      Cell Phone:  
 e-mail:            
        
             Check where applicable:
     X
 Annual Membership Dues $ 5.00  
  

 Insurance (*see note below)  If your insurance is paid though another club, please  
 indicate the name of the club: 
$ 4.75  
 

    
    
 Swingin' Singles Name Badge
 Standard Fastener     Singles Badge, Blue      Married Badge, White
 Magnetic fastener      Singles Badge, Blue      Married Badge, White

$ 7.50  
$10.00  

    
    
 Club Newsletter:
    Email Newsletter to me:
    Mail Newsletter to me via USPS:

N/C    
$10.00  
    


 Fed Facts Subscription - (6 issues annually)
             (Fed Facts pro-rated after December - $3.50 per issue
             
will be subtracted from total if New Applicant is checked)
$21.00  

  
       Kansas TRAVEL-ON Magazine (3 issues per year) $20.00  
     Missouri Doinís Magazine (6 issues annually)
$15.00  
                 Total Amount Due (Make checks payable to Swingin' Singles)

      Would you serve on a committee?      Would you serve as an officer?

       *Note: It is required that all members of Swingin' Singles have USDA Insurance.  To remain eligible for USDA's Liability insurance,
      Swingin' Singles must have 100% of its members insured through our club or another club with Liability insurance.

     The Swingin' Singles reserves the right to refuse membership to anyone whose presence of conduct is deemed by the Board not to
     be in the best interests of the Club or Square Dancing fellowship. (Bylaws Article III, Section 4 & 5)

     For New Applicants:            Sponsor:                                                      Board Member:   

      Please note: There will be a $20 Charge for Returned Checks.                                  07/12/2019



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