$25.00 Per Membership

Name_____________________________________________

Address ____________________________________________________________

City _________________________        State ______   Zip Code ______________

Phone ________________________   E-mail_______________________________

No. of Family Members ____________

Memberships are transferable among immediate family only (father, mother, son, daughter).

Enclosed is my (our) check payable to
the Licking Park District for membership privileges.

Send to: Licking Park District, PO Box 590, Granville, Ohio 43023.