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Please print or type the information below

Name*_____________________________________
(First, Middle, Last) _____ New Member $20
Street*________________________Apt Number * __________
City __________________State___Zip + 4________________
Home Telephone* __________ Work Telephone ___________
Church You Attend *___________________________________
Hometown ___________________________________________
Occupation ___________________________________________
Birthdate * ___________________________________________

Please Check One
_____ New Member $20 _____ Address Change _____ Alumni $17
_____ Subscribing/Non-member $20 ______ Renewal/Alumni $17/Mem $20

Do you want your name, city, hometown, and phone number printed in the CYAC
directory for use by members only? Yes______ No_____

If you would like to help out on any of the following committees, circle below
Cultural Hospitality Social Service Parliamentarian Editor Historian Material Coordintation
Publicity Social Parish Rep. Recreation Religion Computer Opr. Membership

* All information with the asterisk is required for a valid application

I, the undersigned, shall follow all rules and regulations of the Catholic Young Adults Club (CYAC) of the Arlington Diocese as stated in the CYAC Constitution and Bylaws. Upon failure to comply with these rules, CYAC reserves the right to terminate my membership at any time. I understand that the membership dues are not refundable. I will provide my home telephone number for emergency purposes and I will provide my date of birth. I will complete alll required fields in order for my application to be valid. I have provided the most current information and I have not falsified any of the provided information.

I understand that certain activities sponsored by CYAC may be potentially dangerous and may risk injury of loss. Ihereby for myself, my heirs, executors and administrators, waive and release any and all rights and clain that I might have, or that might arise against CYAC, its agents or representatives, the Diocese of Arlington, for any and all injuries of losses sustained by me while participating in or attending events sponsored by CYAC.

To obtain full membership status, I am a single Catholic between the ages of 18 and 35 as defined by church standards. As an alumni member I have previously been a regular CYAC member in good standing. As a subscribing non-member, I will not retain any membership status and will only receive the newsletter.

Name:*______________________________________ Date* _____________
Please mail this application with a check payable to CYAC for annual dues to:
CYAC
P.O. Box 2402
Merrifield, VA 22116