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Membership Application
  1. Membership(*)


    Please enter your membership.
  2. Membership Type(*)




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  3. How did you hear about BASCC?
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  4.  

  1. Master Member

  2. First Name(*)
    Please type your first name.
  3. Last Name(*)
    Please type your last name.
  4. Street(*)
    Please type your street.
  5. City(*)
    Please type your city.
  6. State(*)
    Please type your state.
  7. Zip(*)
    Please type your zip.
  8. Gender(*)
    Please type your gender.
  9. Birthdate(*)
    Please type your birthdate.
  10. Phone(*)
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  11. E-mail(*)
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  12. Second Member

  13. First Name
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  14. Last Name
    Please type your last name.
  15. Gender
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  16. Birthdate
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  17. Member Directory

  18. Senior News Options(*)



    Please select if you would like the Senior News.
  19.  

  1. Emergency Contact Information

  2. New Members: Provide the following emergency information.
    Renewing Members: Update your emergency information.

  3. Master Member

  4. Contact(*)
    Please type your contact name.
  5. Relationship(*)
    Please type your relationship.
  6. Phone(*)
    Please type your phone.
  7. Address(*)
    Please type your address.
  8. City(*)
    Please type your city.
  9. State(*)
    Please type your state.
  10. Zip(*)
    Zip
  11. Medical Concerns
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  12. Second Member

  13. Provide this information if it is different from the MASTER MEMBER.
  14. Contact
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  15. Relationship
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  16. Phone
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  17. Address
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  18. City
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  19. State
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  20. Zip
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  21. Medical Concerns
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  22.  

  1. BASCC Volunteer Opportunities

  2. I am interested in the following opportunities:







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  3. Other
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  4. Release of Claims

  5. In consideration of being enrolled in any BASCC program, I hereby assume all risks in connection with such program, and I further release BASCC, the instructors, and/or agents/operators of such programs for any injury or damage that may befall me while participating in such programs, including all risks connected therewith, whether foreseen or unforeseen; and I further agree to save and hold harmless BASCC, the program and persons from any and all claims by me, my family, estate, heirs or assigns, arising out of my enrollment and participation in such programs.
  6. (*)
    Please accept the waiver.
  7.   
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