Date:___________________

First Name:________________________    Last Name:___________________________________

E-mail:____________________________________________________________________________

Address:___________________________________________________________________________

City/St/Zip:_________________________________________________________________________

Home Phone:______________________________________________________________________

Work Phone:_______________________________________________________________________

Type of Membership:   *Family ($35)___           Single ($20)___          Initiation Fee ($20)___

Total Amount Paid:_______________            Check___                                      Cash___

                                                                    (Payable to CHSC)

*For family membership, list members of immediate household to be included in membership

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Type of Boat (model and color):________________________________________________________

Call Sign:____________________________________________________

Mail to:        CHSC

                   P.O. Box 1593

                   Evans, GA 30809