Amt Pd ______________  Cash (    )  Check #________________           Rec'd by______________________________
_________________________________________________________________________________________________
Please indicate if you would like to volunteer for any of the following:
Advertising/Publicity________
Dance Host/Hostess( dancing with unpartnered attendees____
Outreach_____
Social Greeter (Welcoming newcomers) ______          Activities Participation__________
2019 MEMBERSHIP APPLICATION
Space Coast Dance Club (SCDC)
Signature ____________________________________________________________________
(Membership dues are $30 per calendar year). Make check payable to Space Coast Dance Club, Inc.
Apply at an SCDC event OR mail to:


Space Coast Dance Club
7777 N. Wickham Road Ste 12-701
Melbourne, FL  32940
SPACE COAST DANCE CLUB, INC. (SCDC) is organized and operates as a nonprofit social and educational organization
under the Nonprofit Corporation Act (the “Act”) for the purpose of preserving, studying, teaching and promoting public
interest in all forms of social dancing. SCDC shall not engage in any activity that conflicts with its status as a nonprofit
corporation.

Please PRINT legibly and fill out the application completely.
Name  ________________________________________________________                                      Date ______

Street Address  ________________________________________________                                       Apt#  ______

City _______________________________________________________________    ST____  Zip Code ________

Home Phone _______________________________________                                      Birthday Month  __________

Cell Phone    _______________________________________

Email Address _________________________________________________________________

YOUR INFORMATION IS FOR SCDC USE ONLY. IT WILL NOT BE SHARED.
In consideration for being allowed to participate in this Space Coast Dance Club (SCDC event, I release SCDC, its
respective officers, directors, members, instructors, other participants and the Fraternal Order of Police (FOP) from liability
and waive the right to sue for any and all claims, including but not limited to, claims of negligence, resulting from any
physical injury, loss or damage to personal property, illness (including death) or economic loss or costs which may result
from participation in the SCDC event, travel to and from the event or any activities incidental to the event. I agree to
indemnify SCDC, its respective officers, directors, members, instructors, other participants and the FOP from any and all
liability claims and causes of action connected with participation in this SCDC event. I take full responsibility for my behavior
and for any damage I may cause to the facilities, other participants, or their personal property. I agree to abide by the
SCDC Rules of Conduct found at
http://www.spacecoastdanceclub.com and I grant SCDC permission to utilize
photographs and / or videos of me for advertising and publicity purposes.