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Name __________________________________________

Address ________________________________________


Phones: Day________________ Evening_______________

Email: __________________________________________

INTERESTS (check items of interest to you):

Outings I would like to attend: __ Backpacking __ Camping __ Biking__ Hiking __ Kayaking/Canoeing __ Other (specify)___________

__ I would like to take: ___ First Aid Training ___Outing Leaders Training ___ Other (specify) ____________________________

__ I would like to lead some outings.

ISSUES (I would like to work on): __ Wildlife Issues __ Rivers/Clean Water __ Groundwater __ Clean Air __ Global Warming __CAFOs (Factory Farms) ____  Energy___Sustainable Living/Recycling ___ Clean Air ____Other (specify)________________________________________________________________________________

INVOLVEMENT (check items that interest you):
__ Write Letters __ Review Permits __ Lobby for Legislation __ Attend Hearings __ Serve on a Committee __ Conservation Issues __ Outings __ Education __ Political Committee _____ Fundraising __ Awards __ Membership __ Outreach __ Plan Activities/Events __ Public Relations __ Political/Legislative Action ___ Research ___Other (specify) ______________________

Please mail to:

Indiana Chapter of the Sierra Club, 1100 W 42nd St., Suite 218, Indianapolis, IN, 46208


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