Membership Form

Your PA Jeeps membership will include the following:

Membership to the U.F.W.D.A. & Quarterly Newsletter
Membership to the M.A.F.W.D.A.
Club Membership Card
Monthly Newsletter
Discount Programs with Quadratec & 4WD Hardware
Monthly Trail Rides & Other Family Events & Activities
Copy of Clubs By-Laws
Membership Directory
Yearly Events Calendar
Club “Sponsored” Events (Club covers some / all of event costs)

Membership includes your immediate family. (Spouse, Children, Significant other)

Each member must be an owner or have access to a registered Jeep and be at least 18 years of age, hold a valid automobile operator's license, and have sufficient personal liability and property damage insurance coverage to satisfy all minimum state laws in which the vehicle is legally registered.

Member Contact Information

Name

Cell Phone Number

Home Phone Number

Address

Date of Birth

T-Shirt Size (New Members Only)

List all Allergies and Medical Conditions

Jeep(s) description - Tell us about your rig(s)

Club Directory Release - Do you want your contact info listed in the club directory. This information is only shared with other club members.

Yes, publish my contact information in the Club directory.
No thank you, please keep my contact information private.

Emergency Contact POC

Name

Phone Number

Membership

Membership Options

Initial Membership ($50.00)
This is for new membership only.
Membership Renewal ($40.00)
You are a current member and are renewing for another year.
Membership Renewal (Lapsed) ($50.00)
Membership has lapsed one calendar year or more and you are renewing for the next year.

Membership Number

Running Total

$50.00

Total

$50.00

Terms & Agreements

The undersigned hereby agrees to indemnify and hold harmless the PA Jeeps Club, its members, and officers of any loss, liability, damage, or cost they may incur while attending any Club functions or while volunteering labor towards any event stemming from membership within the Club. This includes any outside events attended and/or sponsored by the PA Jeeps Club, as well as any family members, friends, or guests you choose to bring along.

I have read and agree to the terms above.

Coupon Code

Online Processing Fee

$1.00

Billing Information

Name

Payment Method

Credit Card
Offline

Credit Card

Visa
Mastercard
American Express
Discover

Address

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