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Name: ________________________________	Occupation: ________________________________
Spouse: _______________________________ (if applying for membership)	Occupation: ________________________________

Address: ______________________________
City: _________________________________	State: _____________ Zip Code: _______________

Home Phone: __________________________	Work Phone: _______________________________
Email Address: ____________________________________________________________________

Additional Family Members:
Name: ______________________ Age: ______	Name: ______________________ Age: ______

Basic KCCNY Membership (includes KCCNY newsletter, 4 issues per year):	$20.00	______

Spouse and/or additional Family Members (one mailing per family): (includes voting priviledges for members over 18 years of age)	$5.00	______

American Canoe Association (Required): ACA number if currently a member: _______________	single $30.00 family $40.00	______

American Whitewater Association Membership (Optional): (includes one year subscription to AWA Journal)	$25.00	______

Donation towards Conservation (Optional): (used for conservation purposes only)	sugggested $5.00	______

Initiation Fee, one-time signup fee (Manditory for new members only):	$5.00	______

You can help us save printing and postage costs by not receiving the newsletter in the mail. You can read the newsletters in color on the web.	Check to not recieve the printed newsletters

	Total:	______

Make check or money order payable to KCCNY and send to:

Pierre de Rham
PO Box 195
Garrison, NY 10524
(845) 424-3160