Annual Dues are $24.00 Per Family. Our year runs from January 1st to December 31st.

For new members joining within the clubs fiscal year, dues are prorated at $2 per month.

Please make checks payable to:

Lowcountry Miata Club

143 White Pine Way
Summerville, SC 29485

Today’s Date: ____/____/____

 

Member Name: _______________________________________________________________________  

 

Member Birth Date: _____/_____/_____

 

Spouse/Significant Other: ______________________________________________  

 

 Spouse/Significant Other Birth Date: _____/_____/_____                    

 

Member E-Mail: ______________________________________________________________________  

 

Spouse/Significant Other E-Mail: _________________________________________________________

 

Wedding Anniversary: _____/_____/_____

 

Address: ___________________________________________________________________________  

 

City: __________________________________   State: ________   Zip code: ______________  

 

Home Phone: (__________) -___________-______________                 

 

Cell Phone: (__________) -___________-_____________  

 

Member Occupation: ____________________________________________________  

 

Spouse/Significant Other Occupation: _______________________________________

 

Miata Information

 

Year: __________   Int. / Ext. Color: _________________________________   License Plate #: ___________  

 

Mileage: ______________     Car’s Name: ________________________________________  

 

When did you acquire your car? ______________________________________

 

What interests you about joining the club? (Circle all that apply)

 

 

Socializing           Drives                   Accessories         Discounts             Technical              Group Events   

 

 

 

What would you like to fix, update or change on your car?

 

 _______________________________________________________________________________

 

What are some of your favorite places to eat?

 

_______________________________________________________________________________

 

What type of events would you like the Club to do?

 

_______________________________________________________________________________

 

Where did you hear about the Lowcountry Miata Club?

 

_______________________________________________________________________________

 

That I, my heirs, executors, administrators, and personal representatives do not hold liable Palmetto Mazda,

employees of Palmetto Mazda, the Lowcountry Miata Club, its officers, agents, servant or employees whether acting

officially or not, arising out of affiliation for any actions, complaints, proceedings, claims, demands, injuries, damages,

actions or causes of action which arise wholly or partially due to the negligence of any kind as a result in an organized rally

or scheduled event or meeting organized by the Lowcountry Miata Club.

               I hereby expressly forever release and discharge the Lowcountry Miata Club, Palmetto Mazda, vendors invited by

the Lowcountry Miata Club, their agents and employees from all such claims, demands, injuries, damages, actions or causes

of action, including those for negligence, arising out of or related to any loss, damage, or injury, including death, that may

be sustained by me or my property by reason of my permission to participate in the Lowcountry Miata Club.

 

Member Signature: ________________________________________________________   Date: ____/____/____

 

Spouse/Significant Other Signature: ____________________________________________   Date: ____/____/____

 

 

 


                Club Use Only:

  

                Amount: _________________   Check Number: _________________   Date Received: ____/____/____