SEND THIS FORM TO: USS Athena, P.O. Box 710152, Oak Hill, VA 20171-0152
Don't forget to enclose a Self Addressed Stamped Envelope (SASE)
Make checks out to "USS Athena"

Name:__________________________________ DOB (yr optional):__________

Street:__________________________________________

City/State/Zip:__________________________________

Phone: (_______)________________  Email: ____________________________

Are you a member of any other Trek fan clubs?  Y / N

If "yes", which ones?_______________________________

____________________________________________________

Any special needs we should know about (accessibility issues, allergies)? ___
(if yes, describe briefly)


Interests:
Types of Sci-Fi (check all that apply)
__ Star Trek TOS TNG DS9 VOY TOS-Movie TNG-Movie
__ Babylon 5
__ Farscape
__ Dr. Who
__ X-Files
__ Other (please list): ______________________

Other interests:
__ movies type(s):_______
__ hiking
__ biking
__ bowling
__ gaming type(s):_______
__ board games types(s):___________
__ puzzles
__ online gaming
__ other (please list):____________


Are you under 18? Y/N

Membership plan:  ___ Individual ($12) ___ Family ($15)
(make check or money order out to "USS Athena")


Member signature:_________________________________ Date: _________

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