Membership Application Form

Team or Company Name:	Membership Type:	Comeptition License:
Your Name:	Date of Birth:	Gender:
Address Line 1:	Address Line 2:
City:	State:	Zipcode:
Your E-mail Address:	Work Phone Number:	Home Phone Number:
Reenter Your E-mail Address:	Cell Phone Number:	Fax Number:
== MEDICAL CARD INFORMATION ==
Current Medications:	Height:	Weight:
Medical Conditions:	Eye Color:	Hair Color:
Allergies:	Date of Tetnus Booster:	Blood Type:
Name of Doctor:	Doctor's Phone Number:
Name of Next of Kin:	Next of Kin's Phone Number:

== ACKNOWLEDGEMENT AND DISCLAIMERS ==

I have read the 2010 RELEASE, WAIVER OF LIABILITY, ASSUMPTION OF RISK & INDEMNITY AGREEMENT and I FULLY AGREE to its terms and conditions.

By pressing SUBMIT, I hereby apply for membership with USERA and agree to abide by the USERA Sporting Regulations.

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