FMCA Covered Wagons Application for Membership

Please fill in the blanks and enclose a photograph of you for the chapter directory book

which you receive annually as part of your dues. (If desired, you may email a digital

photo to webmaster@coveredwagonsfmca.org. If you don't have a photo, we’ll take

one of you at your first rally.)

Thank you and welcome to our chapter!

FMCA #__________________(Must be a member in good standing w/FMCA.)

Name(s):______________________________________________________________________
(This is how your names will appear on your name tags so please print clearly.)

Address:______________________________________________________________________

City:_____________________________State:______________________ZIP:_____________

Home phone: _______________________________

Cell Phone: (optional) His:_________________________ Hers:________________________

E-Mail address: _________________________________

Birthday: (day and month only) (His)____________________(Hers)_______________________

Anniversary: (day, month and year) _____________________Number of Children:________________

Native State: (His)_________________________________(Hers)___________________________

Present or Past Occupation: (His) _________________________ (Hers) _______________________

Hobbies: (His)___________________________________________________________________

(Hers)___________________________________________________________________

Make, Model, Year & Length of Motorhome:______________________________________________

Approximate year you started RVing?________________

Pets (breeds and names) traveling with you:________________________________________________

Emergency Contact:_______________________________________________________________

Comments:______________________________________________________________

Please mark applicable lines below & remit check payable to Covered Wagons. Thank you!

___ $15.00 Annual Dues (e-mail available)   ___ $20.00 Annual Dues (NO e-mail available)

Please add $6.00 for each Name Tag

____ I require a pin-back, instead of the standard magnet-back on name tags

Return to: Covered Wagons Date: ______________________
% Sharon Keegan

3049 SW 45^th Street,

Topeka, KS 66610 Revised 1/29/11