Membership Application United States Running Streak Association, Inc

Membership Application United States Running Streak Association, Inc.

Full Name Nickname Date .

Address .

City or Post Office State Zip .

Email Address______Telephone______Date of Birth Age Gender Marital Status . Spouse’s Name Number of Children Occupation . Military Branch Highest Rank . Active, Retired or Type of Discharge . Name of Running Club/Track Team affiliation(s) . Membership level applied for Dues . Starting date of active daily running streak . Starting & Finishing dates of retired running streak . Total number of streak miles run as of application date . Total number of races run as of application date .

On a separate sheet of paper, please provide a brief synopsis (300 word maximum) of your running or racing career, or any other related accomplishments you wish to have mentioned about you.

Also, on a separate sheet, you may provide additional comments about family or non-running related matters you would want to share with fellow members and the running public (up to an additional 200 words). This part is optional. STREAK DEFINITION: A running streak is defined by USRSA as running at least one continuous mile within each calendar day under one’s own body power (without the utilization of any type of health or mechanical aid other than prosthetic devices).

DOCUMENTATION: If so required, applicants agree to submit copies of such portions of their running logs, or other evidence of their running streak, as USRSA may request.

CERTIFICATION: In addition to the membership application, all applicants must submit a signed streak certification form.

Membership dues must accompany this application, and are:

Associate Membership - $20.00 per year. Open to those runners whose running streak is less than one year old. Also open to all runners who are under 21 years of age regardless of the age or length of their daily running streak. Also open to duly organized running clubs, track and cross-country teams, and other groups whose primary mission includes the promotion of the sport of running. Premier Membership - $20.00 per year or $250 lifetime. Open to those runners who have a running streak of at least one year in duration, and are at least 21 years of age. Summit Membership - $20.00 per year or $250 lifetime. Open to those runners whose running streak exceeds twenty (20) continuous years in duration.

(Credit for one-half of all previous dues paid will be applied to payment of lifetime dues. Once lifetime membership status is achieved, no further dues will be assessed.)

Send your fully completed application with proper remittance to:

United States Running Streak Association, Inc. c/o Mark Washburne 31 Galway Drive, Mendham, NJ 07945 Questions: email: [email protected]

I hereby certify or affirm that, to the best of my knowledge and belief, all the information furnished in my application for membership is true and accurate, and that I have not misstated any fact or statement by me herein.

. (Signature)