2011 Individual & Family Membership Application Promotional Rates for FREESTYLE Members Only. ✶RENEWAL
☐ YES ☐ NO ✶REQUIRED INFORMATION ✶MEMBERSHIP TYPE (Check One) ✶USACK MEMBER # (if Renewal): ☐ BRONZE Adult* Annual $20 ✶ ☐ JUNIOR** Annual $15 BIRTH DATE:
☐ FAMILY*** Annual $60 ✶FIRST: MI:
* Adults are considered 18 years of age ✶LAST: at time of renewal **Under 18 years of age only ***Max 2 adults per household ✶GENDER: ☐ MALE ☐ FEMALE
USACK DONATION FORM (Optional) ✶ADDRESS:
☐ $50 ✶CITY: ☐ $100 ☐ $500 ☐ $1000 ✶STATE:
☐ GENERAL CONTRIBUTION ✶ZIP: $ ✶PHONE HOME:
☐ DISCIPLINE $ PHONE CELL:
☐ SPECIAL PROJECT PHONE WORK: $ ✶EMAIL: ✶TOTAL CREDIT CARD INFORMATION ✶PAYMENT METHOD (Check One)
☐ VISA ✶NAME ON CREDIT CARD: ☐ MC ☐ AMEX ✶CREDIT CARD #: ☐ DISCOVER ☐ CHECK (payable to USACK) ✶EXP DATE: ✶SECURITY CODE: ☐ CASH ☐ MONEY ORDER TOTAL TO BE CHARGED ON CREDIT CARD: MAILING ADDRESS
330 S. Tryon Street, Lower Level ✶EMERGENCY CONTACT Charlotte, NC 28202 P 704.348.4330 EMERG CONTACT: F 704.348.4418 www.usack.org EMERG CONTACT PHONE:
1 2011 Individual & Family Membership Application Promotional Rates for FREESTYLE Members Only.
✶MEMBER CLASSIFICATION (Check all that apply) FOR FAMILY MEMBERSHIPS ONLY (Provide name and birth date. Attach list of additional juniors, if any.)
☐ ATHLETE ADULT: ☐ FAMILY/FRIEND ☐ OFFICIAL JUNIOR: ☐ CLUB ADMIN ☐ COACH ☐ VOLUNTEER JUNIOR: ☐ RACE ORGANIZER ☐ DONOR JUNIOR:
USACK STAFF JUNIOR:
JOE JACOBI Chief Executive Officer ✶CLASSIFICATION Ext. 221 ☐ FLATWATER SPRINT ☐ WHITEWATER SLALOM ☐ CANOE/KAYAK POLO GERALD BABAO Operations & Membership Director ☐ MARATHON ☐ WILDWATER ☐ CANOE SAILING ☐ OUTRIGGER ☐ FREESTYLE Ext. 225
WILLIAM IRVING ☐ DRAGON BOAT (Must CIRCLE ONE primary area of interest AND CHECK ALL other areas of interest.) National Teams Director Ext. 226 Circled choice will determine which discipline you may vote in for elections (only adult members are eligible to vote.)
MAILING ADDRESS ✶MEMBER CLUB (if applicable): 330 S. Tryon Street Lower Level ✶MEMBER SIGNATURE: DATE: Charlotte, NC 28202 P 704.348.4330 F 704.348.4418 Approved by (Office Use Only): DATE: www.usack.org
USACK WAIVER & RELEASE OF LIABILITY MUST ALSO BE COMPLETED FOR PROCESSING.
If you have any questions about your membership, or need help completing your renewal, please con- tact 704.348.4330, ext 225.
ABOUT USA CANOE/KAYAK
The USA CANOE/KAYAK mission, “To realize the dreams of competitive paddlers”, is designed to pro- mote and support competitive paddling in the United States including but not limited to the Olympic sports of Slalom and Sprint canoe/kayak and World-Paddling Sports.
A member of the United States Olympic Committee (USOC), USA CANOE/KAYAK is the National Gov- erning Body (NGB) responsible for the management and the development of the Olympic sports of Flat- water Sprint and Whitewater Slalom and World Paddling Sports (Marathon, Freestyle Rodeo, Wildwater, Polo, Canoe Sailing, Outrigger, and Dragon Boat) in the USA. Internationally, USA CANOE/KAYAK repre- sents the USA to the International Canoe Federation (ICF) and the International Olympic movement.
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