Least Resistance Training Concepts, Inc. / Wild Horse Mentors
Mentor Enrollment / Membership Application
(Rev. 04/06)

Name: Address:
City: State / Zip:
Telephone:                                          Mobile: Email:
D.O.B. OK to publish city / telephone? OK to publish email?
OTHER FAMILY MEMBERS TO BE INCLUDED
NAME: BIRTHDATE:
NAME: BIRTHDATE:
NAME: BIRTHDATE:
NAME: BIRTHDATE:
(EACH FAMILY MEMBER NEEDS TO FILL OUT A SECTION ON PAGE 2.)
I hereby apply for membership in LRTC / Wild Horse Mentors and agree to abide by the policies and procedures adopted by BLM and LRTC.

________________________________
(Applicant) 		__________
(Date)
Please send completed application and payment to:
    L.R.T.C.
    C/O Betty Retzer
    11625 US 50 West
    Stagecoach, NV 89429
Membership Fees
  • Single Mentor Membership (Note 2)
$ 15.00  
  • Family Mentor Membership (Note 2)
$ 25.00  
  • TOTAL:
 

All memberships expire on December 31st.

Please make checks payable to: Least Resistance Training Concepts (L.R.T.C.)

LRTC OFFICE USE ONLY
YEAR: SINGLE / FAMILY AMT. PAID: CHECK #: DATE:
         
         
         
         






Additional Family Member Enrollment Form

This section is used to enroll participating family members (other than the original Family Membership applicant.) Please have each participating member print his or her name in the space below and sign, be sure to sign below for any minor children, and submit this form with your Membership Application.

For the purpose of this application, a "Family Member" may be any person who lives permamently in the same family household as the applicant.


I (name) ___________________________ hereby apply for membership in LRTC / Wild Horse Mentors and agree to abide by the policies and procedures published by BLM and LRTC.

________________________________
(Signature) 		__________
(Date)


I (name) ___________________________ hereby apply for membership in LRTC / Wild Horse Mentors and agree to abide by the policies and procedures published by BLM and LRTC.

________________________________
(Signature) 		__________
(Date)


I (name) ___________________________ hereby apply for membership in LRTC / Wild Horse Mentors and agree to abide by the policies and procedures published by BLM and LRTC.

________________________________
(Signature) 		__________
(Date)


I (name) ___________________________ hereby apply for membership in LRTC / Wild Horse Mentors and agree to abide by the policies and procedures published by BLM and LRTC.

________________________________
(Signature) 		__________
(Date)
APPROVAL FOR MINOR CHILDREN:
I hereby grant permission for my minor child/children, named above, to participate in the LRTC / Wild Horse Mentors program and activities whom I do / do not want listed on the web site as a mentor who can be contacted. (Please circle one.)

________________________________
(Parent / Guardian Signature) 		__________
(Date)