Name:________________________________________________________________________
Address:______________________________________________________________________
City:_______________________________________
State:________ Zip:_______________
Home Phone:__________________________
Work Phone:__________________________
E-mail
Address:_____________________________________
Required Waiver:
I hereby certify that I have been notified that the Madison West Coast
Swing Club, its board, members and instructors accept no responsibility for
injury occurring out of or from my
participation in or travel to any club meeting, class, dance or function. I have
been advised to carry my own medical and accident insurance.
Signature (req'd):______________________________________
Date:__________________
Membership Directory:
 Include me in the membership directory (sign below;
if neither is checked, you will be included)
Exclude me from the membership directory (sign below)
Signature (optional):____________________________________
Date:__________________
I
would like to receive my newsletter via e-mail
(be sure to enter address
above)
I
would like to receive my newsletter by post-office
(if left unchecked, none will
be sent)
Payment and Application:
Enclose $20 for a one-year membership. Checks payable to:
Madison West Coast Swing Club
Send to:
MWCSC, c/o
Membership Director, P O Box
258067, Madison, WI 53725
Website: http://www.mwcsc.org
Thanks for your
interest! Optional: How did you hear about us? Check all that apply:
At a Dance At the Badger
Bowl On a flyer Your
website
Newspaper______________________ A friend told me
(who)_____________________________
From another club ________________ At a social function
(which)_________________________
Other
___________________________________________________________________________
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