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Annual Dues Statement/Membership Verification, 2005 Season

Please take a moment to check and correct your family information on this form.

Please mail checks on or before May 1, 2005 to: LPRC, PO Box 243, Annandale, VA 22003

                                              MEMBER(S) INFORMATION                                     CHILD'S NAME                       DATE OF BIRTH

Member Name(s):








City, State, Zip:




Telephone #:







2004 Annual Fee Calculation (definitions on reverse) - Check one and insert corresponding dollar amount in the column to the right.

Basic Membership:  (Check one)                             

           Basic Membership   (2 persons) ($360)                                 Basic Membership + 3 dependent children  ($405)

           Basic Membership + 1 dependent child ($375)                     Basic Membership + 4 dependent children ($420)

           Basic Membership + 2 dependent children  ($390)              Basic Membership + 5 dependent children ($435)






Individual Member     $295


Individual Member




Senior Individual        $215


At least 60 years of age




Senior Basic Memb.    $245


2 Senior members, Both 60+ years old,  residing at same address


Inactive Fee                 $110

Due on or before July 1st, 2004.


Late Fee                        $50

For Active fee postmarked after 5/1/04 or Inactive fee postmarked after 7/1/04


Seasonal Guests            $80

$80 each….Enter Name(s) and relation to member: _________________________




Guest Passes                 $45

Earn 10 free guest passes by getting a new member to sign up.

10 for $45.  Enter number of books           X $45 (Passes at the gate will be $5)




WORK FEE      $75

(waived for 1st year members)

Work fee applies to all active members (if you intend to work off your work fees, please include a separate check for $75, which will be returned or destroyed upon completion of work hours) Please circle interest(s):  clean-up/work parties, engineering, membership, social programs,  newsletter, swim program,  tennis program, other: ________________________________







Team Fees

# of children participating in swim team        ($50/child or $130 family maximum)

Child's Name:_____________________  Swim

Child's Name:_____________________  Swim

Child's Name:_____________________  Swim

Child's Name:_____________________  Swim




JUNIOR TENNIS       Team Fees



(see reverse side for description)

TENNIS TEAM: # of children participating in team______($25/child or $65 family maximum)

Name(s) of Children for TENNIS TEAM:____________________________________________

Refer to the newsletter for fees & schedules. Updates to these are posted at:

JUNIOR DEVELOPMENT PROGRAM (JDP):  ($20 per 4 day week per child or special rate of  $125 for 7 weeks if paid with dues or by May 23rd.

Name & # of Weeks:______________________  Name & # of Weeks ______________________

Name & # of Weeks:______________________  Name & # of Weeks______________________











Interested in Water Aerobics?  (Circle 2 days which you would like to have a session):  MON  TUES  WED  THURS  FRI  SAT   SUN

Are you willing to help save money and receive your newsletters via email?  Yes/No


What can we do to improve our facility for you and/or potential members?