Wheelchair & Ambulatory Sports, USA

Membership Number

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First Name (*)

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Last Name (*)

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Email (*)

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Gender (*)
MaleFemale
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DOB (*)

Must be mm/dd/yyyy (mm/dd/yyyy)
Address (*)

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Apt, Suite, etc...

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City (*)

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State
Select oneALAKAZARCACOCTDEFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
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Zip (*)

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Phone Hm

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Phone Cell

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Phone Wk

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Work Phone Ext.

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Please select only the sports you will compete in on a regional or national level. Select up to three sports. (Additional sports selections will be $3 per sport)

(*)
ArcheryBilliardsFencingHandcyclingShootingSwimmingTable TennisTrack & FieldWeightlifting
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Qty of additional sports

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Membership Staus (*)
AthleteCoachOfficialPatronVolunteer
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Payment type (*)
New Members $35.00Renewing Members $35.00Renewing Members after March 31st $50.00Renewing Members after May 31st $75.00
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Total Payment (*)

Invalid Input (This amount should include the Membership fee of $35.00, and any applicable late fees, as well as $3.00 for each additional sport selection above your first three selections.)

As a member of Wheelchair and Ambulatory Sports USA (WASUSA) you are also a member of your Regional Sports Organization (RSO) and the National Governing Body (NGB) and/or Sport Technical Committee (STC) of the sport(s) you participate in or support. Your contact information is shared with your (RSO), (NGB) and/or (STC) based on your address and sport choices. WASUSA, the RSOs, NGBs and STCs will not share contact information with an outside entity without receiving your permission. If you do not want your contact information shared with the RSOs, NGBs or STCs please notify us in writing at the time you submit this application.

Liability Release (Must be signed by participant or if under 18, parent or legal guardian.) The undersigned agrees to indemnify and hold WASUSA harmless, and release WASUSA from any and all liability for any injury which may be suffered by the above named individual(s) in any WASUSA events arising out of or in any way connected with participation in WAS USA events except as a rises out of the sole willful act or sole active negligence of WASUSA, its officers, agents or employees. I HAVE READ THE ABOVE AGREEMENT AND FULLY UNDERSTAND THAT I ASSUME ALL RISKS FOR INJURY RECEIVED.

For the purpose of promoting WASUSA and its services/programs. I give my permission with the following understanding: No compensation of any kind will be paid to me (or my child) at this time or in the future for the use of my (or my child's) likeness.

Payments made online or by check are non-refundable and will be considered a donation if a completed application is not submitted within a reasonable time.

If you are making your payment online please enter the Receipt ID number below accurately prior to submitting this form. We cannot process you membership materials with out it.

Your payment and reciept ID number or a signed check for payment of membership fees constitutes your acceptance and signature for the preceding terms.

PayPal Receipt ID (*)

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