Membership Application

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Please complete this form in it's entirety and send a payment of $25 via PayPal to gnomeo@organizedchaoschicago.org

Attach a copy of your driver's license and proof of insurance to the membership committee: admin@organizedchaoschicago.org

First Name *

Last Name *

Address *

Phone Number *

Email *

Occupation

How Did You Learn About Organized Chaos? *

Were You Referred By An Existing OCC Member? If Yes, Whom?

What Type Of Membership Are You Applying For? *

Riding Member

Non-Riding Member

Required

Name Of Primary Emergency Contact & Relationship *

Phone Number Of Your Emergency Contact *

Name Of Secondary Emergency Contact & Relationship

Phone Number Of Your Emergency Contact

Health Insurance Company

Any Pertinent Medical Conditions Or Allergies? *

Bike: Year, Make & Model *

Driver's License Number (must have "M" Class designation if registering as a riding member) *

Motorcycle Insurance: Company, Policy # & Expiration Date *

By checking this box below: I confirm and acknowledge that the details I've contained in this form are true and up to date for me. *

I confirm all the details in this form are true and up to date at the time of completion.

Required

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