Indiana USA Track & Field Individual Membership
Application
http://www.usatf.org/ to sign-up on line
(OR print this out & mail)
Temporary application and number, number will be assigned, sent to National and a card
issued from National within 60 days from date National received. Be sure
to include a SELF ADDRESSED STAMPED ENVELOPE for card return.
Is this a NEW membership or a RENEWAL from last year? (please circle
one)
Previous membership number ______________________
Last Name __________________ First Name ________________ MI ____
Address ______________________________________________________
City, State, zip _______________________________________________
Sex: [
]Male [
]Female
Age today: [ ]
Date of birth: [ -
- ]
US Citizen: [ ] yes [ ]
no
- if no, country of citizenship
_____________________
Phone #________________________ E-Mail Address:
_____________________
Club number:___________Club name:__________________________________
| Member categories: |
[ ] Athlete-youth - proof of age is required |
| [ ] Parent |
[ ] Athlete-open/veterans |
[ ] Coach |
| [ ] Official |
[ ] Administrator |
[ ] Contributing Member |
| Sport categories: |
|
|
| [ ] Track |
[ ] Field |
[ ] Road Running |
| [ ] Ultra running |
[ ] Race walking |
[ ] Cross country |
By signature below, I, a prospective member of USA Track & Field -
in, agree to abide by the applicable USATF Bylaws, Operating Regulations, and Rules of
Competition for my level(s) and category(ies) of membership.
______________________________________________
__________
signature (if athlete is under age 18,
parent/guardian must sign instead of athlete)
date
| My tax-deductible contribution to |
| [ ] Local Association |
[ ] National Teams |
| [ ] Training Centers |
[ ] Junior Olympics |
| [ ] Other __________ in the amount
of [ ] $10 [ ] $25 [ ]
$50 [ ] $100 [ ] $500 |
| [ ] Other __________ is enclosed. |
Mail this form with your check and self addressed envelope to:
IN USATF, c/o Judy Wilson - P.O. Box 5792 - Bloomington, IN 47404
Phone number is 812-331-0940(H);
Membership Fees:
Fees for Indiana - USATF Track & Field membership are $15 for youth (under the age of
18 )and $20 for adults. Remember that - except for the contributing membership - only
one fee ($15 or $20) is currently required for as many member categories as you wish
to indicate.
IMPORTANT INFORMATION FOR PROSPECTIVE YOUTH ATHLETE MEMBERS:
1. Coach may sign with permission of parent 2. New or lapsed membership must
submit copy of birth certificate or other ID.
3. A self-addressed stamped envelope should be included for return of card.
AMOUNT ENCLOSED: Total:
$____________