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Membership Form for 2019 - 2020

To be included in the Directory, this Completed Form and Dues must be received by September 30, 2019


Last Name ______________________________ First Name _______________________________ Spouse Name _____________________

Street Address _____________________________________________________________________

City/State/Zip ______________________________________________________________________

*If one number is preferred over the other, please place an asterisk in front of the preferred number

Home Ph ________________________________  Cell Ph ________________________________ Birthday Month______________________Day __________

Email ______________________________________________________________________________

(If you do not provide an E-mail address, you will not receive periodic E-mail updates with pertinent information.)

New Member _______ Renewing Member _______ **Honorary Member (must be a renewing member, age 75 or older) _______

**Honorary Member - Current members age 75 or older are not required to pay yearly dues; however, by choosing this option they forfeit

their voting privileges (Guide and Directory, Page 3, Constitution, Article III, Section 2.)

If you have provided an E-mail address, the Monthly Newsletter will be sent directly to your inbox.

To receive a Monthly Newsletter By regular mail, please check here _______

I hereby acknowledge that KSANC is not liable for any injury, accident or loss which I may sustain at any club


Please sign ______________________________________________________ and date ____________________________

Please send your check for $25.00 yearly dues, payable to KSANC together with your completed Membership Form

(please do not staple or tape check to form or cut away any part of this form) to: 

Membership Chair:  Carol Buckwalter, P. O. Box 171, Landenberg, PA 19350

(To be included in the Directory, your form and dues must be received by September 30, 2018)   

We would be pleased to know how you heard about KSANC:      _____Friend   _____Neighbor   _____Local Newspaper  

_____Website    _____ Flyer   _____Real Estate Agent   _____Other