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New Renewing

First Name
Last Name

E-mail Address:
Re-enter E-mail Address:

Birthdate (month/day) /
Gender: Male Female
Employer
Occupation/Title
Business Phone

Degree Associate Bachelors Masters Doctorate Major
College
Year Graduated
College Location: City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Deleware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississppi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming

1. Are you Catholic? Yes No
2. Are you free to marry in the Catholic Church? Yes No
3. Are you or have you ever been married? Yes No
4. If #3 is "yes," have you obtained a divorce? Yes No
    If divorced, have you obtained a Church annulment? Yes No
    Are you widowed? Yes No

Current Parish
Location

If accepted, would you like to be listed in our club roster?
Yes No

If yes, check items you wish to be included:
NAME CITY PHONE E-MAIL

If new, where did you hear about the Club?

Membership

Check membership status for which you are qualified. (Must be free to marry in the Catholic Church and at least 21 years of age.)

Full Membership (single, Catholic, 4 year college graduate)
Associate Membership (single, not a 4 year college graduate)

I CERTIFY THAT I AM 21 YEARS OF AGE OR OLDER AND THE INFORMATION GIVEN IS BOTH TRUE AND COMPLETE. I UNDERSTAND THAT FALSIFICATION OF ANY INFORMATION WILL RESULT IN THE VOIDING OF THIS APPLICATION AND THE FORFEITURE OF ANY FEES PAID. I ALSO RELEASE THE CATHOLIC ALUMNI CLUB, ITS MEMBERS, AND ITS OFFICERS FROM ANY SUITS OR CLAIMS THAT MAY RESULT FROM AN INJURY OR ACCIDENT WHILE ATTENDING A FUNCTION. I, THE UNDERSIGNED, BEING A MEMBER OF SAID ORGANIZATION, BEING DULY AWARE OF THE RISKS AND HAZARDS INHERENT IN CONSUMING ALCOHOLIC BEVERAGES AND DRIVING UNDER THE INFLUENCE, HEREBY ELECT VOLUNTARILY TO PARTICIPATE IN THE FUNCTIONS, AND I ACCEPT ALL RISK OF DOING SO AND ACKNOWLEDGE THAT ANY ACTION TAKEN ON MY PART WAS NOT THE RESULT OF ENCOURAGEMENT OR INFLUENCE OF ANY TYPE BY SAID ORGANIZATION, ITS SERVANTS, OFFICERS, MEMBERS AND/OR MEMBER'S GUESTS. I INDEMNIFY AND HOLD HARMLESS SAID ORGANIZATION, ITS SERVANTS, OFFICERS, AND AGENTS FROM ANY AND ALL NEGLIGENCE, GROSS NEGLIGENCE, WILLFUL AND/OR MALICIOUS CONDUCT ON MY PART CAUSED BY THE CONSUMPTION OF ALCOHOLIC BEVERAGES AT SAID ORGANIATION'S FUNCTIONS. I HEREBY ACKNOWLEDGE THAT THE AFFIXING OF MY SIGNATURE HERETO BEARS EVIDENCE TO THE FACT THAT THIS IS DONE VOLUNTARILY WITH FULL KNOWLEDGE AND UNDERSTANDING OF THE CONTENTS HEREIN AND CONSEQUENCES ATTACHED HERETO. I UNDERSTAND THAT ALL INFORMATION GIVEN ABOVE IS CONFIDENTIAL AND IS NOT AVAILABLE TO THE GENERAL MEMBERSHIP. AN INCOMPLETE APPLICATION CANNOT BE PROCESSED AND WILL BE RETURNED TO ME OR DISCARDED.

Signature (Type legal name)
Date