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| If you need to contact us for general information, call: Karen (630) 393-3226 |
| 1. Use your computer to Print this form. 2. Then complete the form, enclose your check for $30.00 and mail to New Horizons. New Horizons of DuPage Membership Application Check one: _____ New Member _____ Renewal Please print all information Name:______________________________________ ____Male ____Female Address:____________________________________________________ City, State, Zip:_______________________________________________ Email: ______________________________________________________ Home Phone:________________________________________________ _____ Check here if you would like your name, phone number and email address published in the New Horizons Directory. (Only those agreeing will be published). Members who are given a copy of the Directory are prohibited from copying, selling, or disseminating the Directory to any person.) I verify that I am single and at least 35 years of age. I accept that deliberately falsifying any information will result in the termination of my membership and forfeiture of any membership dues I have paid. I acknowledge that the membership dues are non-refundable. I will conduct myself in an orderly and honorable fashion. I will conduct myself in an orderly and honorable fashion. Inappropriate behavior towards the group, its members or at any event will be reviewed and action taken if appropriate. I have read and I acknowledge and agree to the terms of the waiver below. Waiver: In consideration of being permitted to join New Horizons of DuPage (“New Horizons”) and/or participate in New Horizons’ events or activities, I, on behalf of myself, my heirs, personal representatives or assigns, do hereby release, waive, discharge, hold harmless and covenant not to sue New Horizons, its officers, directors, committee members, invited guests, speakers, and agents from liability from any and all claims including the negligence of New Horizons, its officers, directors, committee members and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to, membership in and/or participation in any New Horizons’ events or activities. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. _____________ _________________________________________ (Date) (Signature) Complete the enrollment form, sign & date. Enclose your check for $30.00 made out to New Horizons and mail to the following address: New Horizons P. O. Box 5161 Naperville, IL 60567-5161 |