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Teche Membership Application Form

Date ________________

Last name _______________________________________ First Name ________________________

Address __________________________________________________________________________

City ______________________________________ State _________ Zip __________ - __________

E-mail address _________________________________________

Telephone ______ -________ - ___________ Date of Birth _____ /_______ / _______

Type of Membership: Check Next to type of membership you would like.

____ Individual, Over 18. - $8

____ Family, Persons residing in the same household. - $10

____ Youth, Persons age 18 or Under. - $5

Total Amount Enclosed $ ________________________

For family membership other than above, please list Names & Birth dates

Names ____________________________________________ Birth date ______________________

Names ____________________________________________ Birth date ______________________

Names ____________________________________________ Birth date ______________________

Names ____________________________________________ Birth date ______________________

Print form, complete application, enclose a check payable to St. Charles Canoe Club

Send this membership form to:
Tave Lamperez 
214 Edgewater Dr..
New Iberia, LA 70560

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Send questions & news letter Information to:
Teche Canoe Club
c/o Tave Lamperez
214 Edgewater Dr.
New Iberia, LA 70560