Membership Application

AMA Charter #553 · Irwin, PA

This application is anewrenewal

Your details

Full nameAMA number(optional)FAA / UAS number(optional)Street addressCity

StateZIP

Home phoneMobile phoneEmailDate of birth

Other family members

Only needed for a family membership. Leave blank otherwise.

In case of emergency

Contact(name & relationship)Phone

Membership type and dues

Regular — age 19 to 64$40Youth (Jr.) — under 19$20Senior / Retiree — age 65 or any pension$30Family — includes spouse & children under 19+$5Renewal late fee (renewing after 31 December)+$10

Regular — age 19 to 64$40

Total$40

Joining after 1 August? Your membership runs through the following calendar year.

Anything we should know?

Optional, and it goes straight to the club with your application — an address or phone number that has changed, a family member joining or leaving, why your dues are late, or anything else worth telling us.

Your note

Acceptance statement

If accepted into Keystone Clippers RC MAC, I agree to participate in club field maintenance and comply with all Keystone Clippers and Academy of Model Aeronautics (AMA) field and safety regulations. I am aware that modeling may present hazards and I accept and relieve Keystone Clippers RC MAC, its officers, members, and the owners of the flying field from all liabilities for personal injury, property damage, or wrongful death caused by negligence.

I have read and accept the statement above.

Signature(type your full name)Parent / guardian signature(if under 19)

Dues are paid by cheque

Submitting this form sends your application to the club. Make cheques payable to Keystone Clippers RC MAC. Contact Eric Haberman for where to send payment. Questions? Call 412-337-5799 or email eric_haberman@yahoo.com.