Adventure
Club US Postal Mail Registration
Please print this form and mail to Adventure
Club,
30 DAY SATISFACTION GUARANTEE - If,
within the first 30 days, you decide the Club is not for you, you will receive
a full refund, less the $15 origination fee pp. as explained in the Statement
of Information and Membership Agreement, as well as, any discounts you received
as a member for any events/trips attended.
Membership : ONE($75):__ TWO($120): __ If for TWO
please indicate Friends: __ or Couple: Dating __ Married __
Which News?___ Email News OR ___Phone System
(You must call our Hotline)
Where did you hear about us? (Just check One) __Google
__Friend __Member __Creative Loafing
__Selective Singles__AOL __Dollie
__MSN __Radio__96Rock __RadioY100 __TV __Yahoo
__Other Club __Other Newsletter __Other Search Engine
FIRST MEMBER
Name:_____________________________________________________________ Sex:____
Age:_______
Address:_______________________________________________________________________________
City:______________________________________________________ State:_________
Zip:__________
Home Phone:_________________________ Work
Phone:_______________________________________
Email:__________________________________ Cell
Phone:_____________________________________
Birthdate:____________ Birth
Place:______________________________________ Smoker: Yes__ No__
Occupation:_______________________________
Employer:____________________________________
Referred by:____________________________________________________________
Would you like to help on a committee? Activity____ Newsletter____
I have read and accept the terms of the Membership Agreement.
Only if paying by credit card, specified below, I also authorize Adventure
Club, a d/b/a of Adventure Club, Inc. to charge my MasterCard, VISA or American
Express for the amount as indicated or the full amount of the Membership
checked above if no specific amount is filled in.
Signature:_____________________________________________________________________
For Credit Card Payment Indicate Type of Credit Card Here
Mastercard____ Visa____ American Express____
Enter Amount to be Charged Here:___________
(only if splitting between 2 Credit Cards - otherwise the total amount will go
on the only card submitted)
Enter your credit card number here:__________________________________________
Expiration Date:_______
By submitting the Credit Card information above you are certifying that the
Credit Card BILLING address is that indicated above. If the address is not the
same please indicate the correct address below.
_____________________________________________________________________________________
SECOND MEMBER
Name:_____________________________________________________________ Sex:____
Age:_______
Address:_______________________________________________________________________________
City:______________________________________________________ State:_________
Zip:__________
Home Phone:_________________________ Work
Phone:_______________________________________
Email:__________________________________ Cell
Phone:_____________________________________
Birthdate:____________ Birth Place:______________________________________
Smoker: Yes__ No__
Occupation:_______________________________
Employer:____________________________________
Referred by:____________________________________________________________
Would you like to help on a committee? Activity____ Newsletter____
I have read and accept the terms of the Membership Agreement.
Only if paying by credit card, specified below, I also authorize Adventure
Club, a d/b/a of Adventure Club, Inc. to charge my MasterCard, VISA or American
Express for the amount as indicated or the full amount of the Membership
checked above if no specific amount is filled in.
Signature:_____________________________________________________________________
For Credit Card Payment Indicate Type of Credit Card Here
Mastercard____ Visa____ American Express____
Enter Amount to be Charged Here:___________
(only if splitting between 2 Credit Cards - otherwise the total amount will go
on the only card submitted)
Enter your credit card number here:__________________________________________
Expiration Date:_______
By submitting the Credit Card information above you are certifying that the
Credit Card BILLING address is that indicated above. If the address is not the
same please indicate the correct address below.
_____________________________________________________________________________________
Note:
__________________________________________________________________
Adventure Club and Club
Esprit are d/b/a's of Adventure Club, Inc, Serving
Atlanta Singles and Couples since 1988
Please send this completed form, with
credit card info or check made payable to Adventure Club to:
Adventure Club -
PO Box 501064, Atlanta, GA 31150