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Membership Application

To apply for a membership, please print this form, fill out and sign the bottom portion. You may bring it to the next club meeting or send it in.  The annual membership fee is $40.00 for 4CCC and Colorado Association of 4 Wheel Drive Clubs dual membership.   Please make your check payable to "4 Corners Canyon Climbers”

Please remit this form with Payment to: 
Flint Boardman ~ 35665 Hwy 184 ~ Mancos, CO 81328

Return to 4 Corners Canyon Climbers Home Page

  Name _____________________________________________ D/O/B __________________

  Spouse ___________________________________________ D/O/B __________________

  Address ___________________________________________________________________

  City _____________________________________ ST ______ Zip ___________

  Phone (home) ____________________ (work) ____________________

  Email Address ________________________________________________________

  Emergency Contact - Phone - Relation _______________________________________________________

  Do you have a valid drivers license?  NO ____  YES ____   Drivers License # ____________________ State _____

  Do you carry the required amount of liability insurance for your state? NO ____  YES ____

  Year of vehicle ______  Make/Model _____________________________________________

Special Equipment _______________________________________________________________

  What level of 4 wheel driver are you? Experienced ____   Moderate ____  Beginner____

  What do you think you would most enjoy in this club?

Technical runs ____   Moderate to hard runs w/ alternate routes ____ 
Tourist/scenic runs ____  Camp-outs with runs ____

Other comments: ________________________________________________________________

By joining the 4 Corners Canyon Climbers of Cortez, I signify that I am aware of the risks and dangers involved.  In the case of an accident where I or my vehicle are hurt or damaged in any way, I hereby release the 4 Corners Canyon Climbers for all liability and responsibility.

Signature: _________________________________________ Date: ___________________

BY SIGNING THIS FORM, YOU ARE AGREEING TO THE BYLAWS THAT GOVERN THE 4 CORNERS CANYON CLIMBERS CLUB -- Updated 3/15/03