3603Stoneybrook Road, Randallstown MD 21133-4227
410-922-0302/patclark@flash.net

MEMBERSHIP FORM

Dues for the calendar year are $24.00 per household.
Please make your check payable to the Fieldstone Community Group, Inc. and send it along with this completed form to:
Fieldstone Community Group, Inc., CIO Gene Weinzweig, 3616 Briarstone Road, Randallstown MD 21133.
You will receive all communications and notices of all meetings, events, etc.
Feel free to photocopy this form and pass it along to your friends (they may not be on our current mailing list) - all are welcome!

Please complete the information below as accurately and clearly as possible:

NAME	NAME OF SPOUSE:
OTHER HOUSEHOLD MEMBERS & AGES:
ADDRESS:
DATE YOU MOVED TO THE FIELDSTONE COMMUNITY:
Please indicate (below) which telephone numbers belong to which individuals:
HOME PHONE: WORK # 's: FAX #'s:
PAGER #'s:	CELL PHONE #'s:

If you are a renewing member please tell us what you believe our achievements and shortcomings were and what you think we should do
differently this year?

Are you interested in volunteering for or participating in the community group? [YES NO]
What activities or events (other than the annual picnic) would you like the community group to organize?

What issues or concerns would you like the community group to address?

In addition to a newsletter, we are considering creating a Fieldstone Community Group Web page.
Do you have access to the Internet? [YES NO] Please indicate your e-mail addresses and the people associated with them:

Much of the business of the Group is conducted by the Executive Board and all Committee members via e-mail. Do you wish to be
included in this e-mail list thereby enabling you to receive (via e-mail rather than bv regular mail) ail communications of general
interest involving the goings on in our neighborhood? [YES NO]

**** Please feel free to provide additional comments and suggestions on the reverse side *****