CBSC Member Payment Form (Please Print Legibly)

1. Bondholders or Senior Citizens Name(s) ________________________________ Address _________________________________ Phone# _________________________________ Join our mailing list online or give us your email address ____________________@___________

2. Individuals Please complete the information below for all children and adults living at the address listed above. Children not yet 3 on June 15th should be listed but not counted in the Total Residents in Household. Please note each child's Date of Birth. Name Child's Date of Birth ____________________________________________________ __________________________ ____________________________________________________ __________________________ ____________________________________________________ __________________________ ____________________________________________________ __________________________ ____________________________________________________ __________________________ ____________________________________________________ __________________________ ____________________________________________________ __________________________ ____________________________________________________ __________________________ ____________________________________________________ __________________________ 3. Dues Assessment (consult fee schedule for appropriate amount) Amount Due Total Residents in Household #__________ $__________ OR Senior Citizen Associate Membership $__________ 4. $50 Bond Payment (new members only) $__________ 5. Initiation Fee ($350 or installment, new members only) $__________ 6. Guest Cards: _________ cards @ $10 per card = $__________ 7. Total Amount Due $__________ New members only: name of current member who referred you _________________________ Please make check payable to "Covered Bridge Swim Club, Inc." mail check and this form to: Covered Bridge Swim Club P.O. Box 1203 Cherry Hill, NJ 08034

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