Return this completed form with payment to: Beulah Recreation

Beulah Recreation Association, Inc.
P.O. Box 37324
North Chesterfield, Virginia 23234
New Membership Registration 2015
This form must be completed and signed prior to processing your membership.
Please read each membership category below and mark which type applies to you. There is a one time
Registration Fee of $200 for new members. If you have questions, please contact Mary Anne Huband,
Membership Secretary at 804-464-1570.
__________ Family (Head of household and spouse/domestic partner, if any, with all dependent children who can
be claimed as an exemption on their Federal Income Taxes) $385 .
__________ Limited Family (one adult and one single dependent child) $310 .
__________ Single (one individual 18 years or older) $235 .
__________ Couples (one adult and one adult spouse/domestic partner residing at the same address with no
dependent children) $347 .
___________ One Time Registration Fee of $200 (must be paid in full).
Member Name:________________________________________________ DOB:________________ Age:_______________
Spouse:_______________________________________________ DOB:________________ Age:_______________
Address:___________________________________________________________ Home Phone:________________
City: _________________________________________ State: ______________________ Zip: _________________
Email: _______________________________________________________ Communications may be sent via email (if you require U.S.
Postal service in lieu of email please provide written request).
Dependent name:__________________________________Relationship to applicant:___________ DOB:__________
Dependent name:__________________________________Relationship to applicant:___________ DOB:__________
Dependent name:__________________________________Relationship to applicant:___________ DOB:__________
Dependent name:__________________________________Relationship to applicant:___________ DOB:__________
Emergency Conact:_____________________________ Relationship:__________________ Phone:________________
Member Signature:____________________________________________________ (REQUIRED)
Return this completed form with payment to:
Attn Mary Anne Huband
Beulah Recreation Association, Inc.
PO Box 37324
North Chesterfield VA 23234
A $45 processing fee will be assessed on checks returned by your financial institution.
Date Received: __________________Received By: _______Member #_____________
Membership Dues Paid: ___________Joining Fee Paid: __________Check #: _______Cash:_______