Name: ______Phone: ______Date:_____

If Family Membership, you must detail the number and names ofonly the additional family members in the same household who will participate in meetings, field trips and other BMC activities (we need this info for insurance purposes, but it costs the club a lot per person, so please don’t list those unlikely to attend/participate):

Number of additional participating family members: ____ Name of Spouse/Partner:______

Names of children under age 21*:______

*If your child is older than 21, then they are required to have their own Individual membership at $15.

Street Address: ______

City/Town: ______State: ______ZipCode: ______

Email Address: ______(receive timely field trip, meeting, mineral show and other important club announcements)

I would like to receive the newsletter as follows (check one):

Send a live link for newsletter to my email above______Mail newsletter to my home address______

Type of membership chosen(check one): Family ($20) ______Individual ($15) ______

Term of Membership and Dues: BMC memberships run January – December. New members joining after Oct. 1st will have their dues credited through the end of the following year.Membership dues are due on January 1st.

Please make checks payable to: Boston Mineral Club, Inc.

Mail the dues and this form to:

Boston Mineral Club, c/o Barbara Wagner,Membership Coordinator, 4 Capricorn Lane, Townsend MA 01469

Please do not include my email address, home address, and phone # in any distribution of membership information to all BMC members.Only my name will appear in any distribution.

BMC PRIVACY POLICY: For purposes of planning field trips and other BMC activities, the club may annually distribute a listing of member names, addresses, telephone numbers and email addresses to all club members. You can choose to exclude your information from our annual member listing by checking the box above. The current BMC officers will always be provided with the complete set of information that you provide. The BMC officers will never knowingly distribute your address information to any other group or organization for any purpose.

BMC Emails:BMC also maintains a private email list server, “BMC-announce”, that permits BMC officers and committee leaders to communicate to the full membership list via email. BMC also has a 2nd email list server, “BMC-discuss”, that allows all members to communicate regarding the club and the mineral collecting hobby. Member emails will be added to both list servers, but members can elect to drop out of these email lists at any time.

IMPORTANT NOTE: We must have a SIGNED copy of your application/renewal form on file.

As a condition of membership, and in consideration of the valuable mineral collecting and other educational opportunities available to me as a club member, I hereby agree to hold the Club and its officers, Directors, committee members and agents harmless, and to indemnify them against any loss and claims arising from my or my family’s participation in Club activities.

REQUIREDSignature of adult member:______Date:______

Thank you for your support of the Boston Mineral Club 2018!(website)

Form MF1-16