IF YOU DO NOT PLAN TO ATTEND THE MEETING A $5.00 PER YEAR

SICK JACK-ASS FEE IS REQUIRED TO CONTINUE TO RECEIVE HEWGAG

MAIL TO: GDR, P.O.BOX 5136, MODESTO, CA 95352

NAME (print) ______________________________________________________________________________________________

Last First Middle

____ Reserve one Grubstake. $30.00 enclosed ____ I am a member of Estanislao #58 ____________(year joined)

____ CHANGE ADDRESS

___Sick Jack-Ass. Keep me on the mailing list. $5.00 enclosed ____ I am a guest. I belong to Chapter ______

I the undersigned, intending to be legally bound hereby, for myself, my heirs, executors, administrators and assigns, waive and release any and all rights and claims for damages I may have against Estanislao Chapter 58, E Clampus Vitus, Grand Council, and their or it's officers, directors, trustees, subcommittees, agents, representatives, and members of the meeting for any and all losses and injuries suffered by me at this meeting. I understand and agree that medical or other services rendered to me by or at the instance of any of the above parties is not an admission of liability to provide or continue to provide any such services and is not a waiver by any said parties of any right hereunder.

$20 CHARGE FOR ALL RETURNED CHECKS

Signature___________________________________________________Date_______________________________

_____________________________________________________________________________________________

FOR OFFICIAL USE ONLY

Check No. _______________________ / ______________________________________________________

CHANGE OF ADDRESS - REQUEST FOR REPLACEMENT CERTIFICATE ___ / ID CARD ___

PRINT BIG AND CLEAR AND COMPLETE

(PLEASE PRINT) ______________________________________________________________________

Last First Middle

(OLD ADDRESS)________________________________________________________________________

Address Street Apt.

________________________________________________________________________

City State Zip

(NEW ADDRESS) _____________________________________________________________________________

Address Street Apt.

____________________________________________________________________________

City State Zip

Member Chpt. _______ Year / Location Joined ____________________ Humbug When PBC_______________

NOTE: FILL OUT COMPLETELY OR FORGET IT - OLD ADDRESS MUST BE FILLED OUT ALSO.

MAIL TO: P.O. BOX 5136, MODESTO, CA. 95352

Sorry, no online registrations or reservations can be accepted. A separate signed release for each person attending and full payment must accompany each registration form.

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