New Member Application

Applicant's Full Legal Name*

Date of Birth*

Nickname*

Are you age 21 or older?*

Address*

Street Address Address Line 2 City State ZIP Code

Mobile Phone*

Home Phone

Emergency Phone*

Emergency Contact*

Email*

Student Pilot

Private Pilot

Commercial Pilot

Instructor

Total time in glider

Number of flights in glider

Total time in airplane

Number of flights in airplane

Date of Last Flight Medical

Date of Last Flight (BFR) Review

Have you failed a flight medical?

Any aviation accidents in the past 5 years?

Please provide details about the aviation accident

Any FAA FAR violations in the past 5 years?

Membership Application & Agreement