Name: _________________________________ Address: _____________________________________

City: ______________________________ State: ____________ Zip: ________________________

Phone: H _________________ W _________________ Email: ________________________________

Emergency Contact: _________________________________ Phone: __________________________

Vehicle Make: __________________ Model: ___________________ Plate: ___________________

State Registered: _______________ Passengers: _______________ 4 X 4? _________________

Sex: _____M _____F Date of birth: __________________ Years Caving: ________________

Certification: Diver ________ NCRC ________ First Aid _______ CPR ________ EMT _______

Caving Activities: ___________________________________________________________________

________________________________ Vertical Experience: ________________________________

Primary Grotto: Met Grotto ____________ Other ________________ NSS# __________________

NEWSLETTER: As a member, you are entitled to receive our
periodic newsletter. Issues are available online (this saves the
organization money). However, if you prefer to be mailed a hard copy of
the newsletter, please initial here: ___________

SPONSORS?: ___________________________________________________________________________

I, _____________________________________________, with address or residing at the
the following address ____________________________________________, hereby release the
National Speleological Society, the Met Grotto of the N.S.S., their officers and
members, vehicle owner and driver, property owner, cave owner and employees, and
others on trips, of all liability of whatever nature might be incurred during, or as a
result of a cave trip. I understand the safety practices of the Society and will abide
by them.

Signed _____________________________________________________ dated ___________________

Parent or Guardian ________________________________________________
(If under 21 years of age, parent or gurdian must sign)

Please return to (and make all checks payable to):
Ayzha Wolf
147 E. 82nd Street #7
NY, NY 10028

(Dues are $15/year, year ends 6/30 -- prorate dues @ $1.25/month
$7.50/year for students under 18 and add'l family members)

Board Approval:
Official Signature: _____________________________________________ date: ______________

rev. 1/22/2007