NE65 Plus Runners Club Application Form

New England 65 Plus Runners Club

Encouraging Senior Runners to Participate in Running and Walking Events
INSTRUCTIONS:

Click your Payment Options: Online with Credit Card or Mail a Check

Please fill out the form below and click the SUBMIT button.

Questions or problems? Please contact David Theoharides, [email protected]
Payment Options*

Pay by Credit Card or PayPal on-linePay by Check and Mail in with Registration form
You are paying by Check

Fill out the form below and Click the SUBMIT BUTTON when finished.
You will receive an email membership confirmation.

Please mail your check to and copy of your membership email to:

New England 65 Plus Runners Club
c/o Lisa DiBella, Treasurer
15 Oak Drive, North Hampton, NH 03862
Name*

First NameLast Name
E-mail*
[email protected]
Phone Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Gender*

MaleFemale
Birth Date*

MonthDayYear
Select SINGLET or T-SHIRT and size from the drop-down menu*
Your membership includes a tech Singlet or T-Shirt
Where did you hear about us?*

From a NE 65 Plus Club MemberA Friend or colleagueGoogleFacebookNews ArticleOther
Please write a brief summary of your running, walking, and/or track & field background
How can you help the Club?*

Helping with Club administration - membership, communication, board member, etc.Helping with Club newsletter - interviews, race results, proofreading, etc.Helping with Facebook page and/or website - e.g. photosHelping with road race planning and organizationHelping organize Club events - e.g. annual luncheonOther
Paying by Check

Please Click the SUBMIT BUTTON when finished.
You will receive an email confirmation.

Please mail your check to
and copy of your email membership confirmation to:

New England 65 Plus Runners Club
c/o Lisa DiBella, Treasurer
15 Oak Drive, North Hampton, NH 03862
State
Please by Credit Card. Please enter payment information below*
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Lifetime Membership
$25.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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New England 65 Plus Runners Club