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Events
CRGTW Decals
Learn More
Join Us
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Membership Application
Blog
Gallery
December 2014
January 2015 Meeting
Topless Tuesday with Louisiana Jeepers
Jambalaya Photoshoot
National Go Topless Weekend 2015
Wild Side Ride 2015
Jingle Jeep Drive
Misc Photos
Taco and Tshirt Meeting
Members Only
Contact US
Home
Events
CRGTW Decals
Learn More
Join Us
Club Documents
Membership Application
Blog
Gallery
December 2014
January 2015 Meeting
Topless Tuesday with Louisiana Jeepers
Jambalaya Photoshoot
National Go Topless Weekend 2015
Wild Side Ride 2015
Jingle Jeep Drive
Misc Photos
Taco and Tshirt Meeting
Members Only
Contact US
Membership Application
*Before you complete the membership application, please review all of the club documents. These can be found under the "Join Us" tab above.
Membership Application
Full Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Jeep Info
Year
*
Model
*
Jeep Description/Modifications
Color
*
How did you find out about us?
*
I received a card.
Friend/Co-Worker
Facebook
Twitter
Instagram
YouTube
Other
Contact Information
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
(###)
###
####
Cell Phone
*
(###)
###
####
Occupation
Email
*
Twitter
@
CB Handle
Family Information
Spouse/Significant Other
First Name
Last Name
Cell Phone
(###)
###
####
Number of Children
0
1
2
3
4
5
6+
Vehicle Insurance Info
Insurance Provider
*
Agent Name
Agent's Phone
(###)
###
####
Policy Number
*
Medical Training
Check All That Apply
CPR Certified
EMR Certified
EMT Certified
Paramedic
Nurse
Nurse Practitioner
Doctor
List Any Other Certifications
Health Information
Medical Conditions
Allergies
Current Medications (Optional)
Emergency Contacts
Primary Contact
*
First Name
Last Name
Primary Phone
*
(###)
###
####
Secondary Phone
(###)
###
####
Secondary Contact
First Name
Last Name
Primary PhoneS
*
(###)
###
####
Secondary Phone
(###)
###
####
Membership Agreement
*
I do hereby declare that I have reviewed all club literature including the Bylaws, Trail Use Info, and Trail Ride Guide. I agree that both I and all guests/passengers in my charge will uphold the principles and abide by the rules outlined in the aforementioned literature. I understand that I may be subject to disciplinary actions at the discretion of the board of directors in the event that I do not abide by the rules and bylaws of this club. Above all and foremost, I declare that I will be a positive ambassador of the Jeep lifestyle, take pride in my club, have fun, and DRIVE A JEEP!
First Name
Last Name
Once you have submitted your application you will receive an email with your approval status. In it there will be a password for the members only area of the website to pay your dues.
Please allow up to a week to receive this email
. If you do not receive this email in that time, please click Contact Us at the top of the page to message the admins.
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