PACIFIC ASSOCIATION/USA TRACK & FIELD ANNUAL MEMBERSHIP APPLICATION

Please print clearly or type all information. Send this completed application with a self-addressed stamped envelope and a check or money order written to PA/USATF to: Pacific Association/USATF, 120 Ponderosa Ct., Folsom, CA 95630

IMPORTANT INFORMATION FOR YOUTH ATHLETES! A birth certificate must be submitted with new or lapsed memberships.

New member? ___ Renewal? ___ Previous USATF Number______________________________

Name:_________________________________________________________________________
                    last name                              first name                                        middle initial

Address:________________________________________________________________________
                         Street or P.O. Box           City                                        State     zip+4

Sex (M/F)_______ Age Today___________ Date of Birth_________________________
                                                                                                        month / day / year

U.S. citizen?_____ if no, country of citizenship_______________________________

Phone Number___________________________________________________________________

PA/USATF Club #_____________ PA/USATF Club Name_________________________________

Email:________________________________________________________

Check the sports in which you compete: __ Track __ Field __ Road
__ Cross Country __ Ultra Running __Mountain/Trail __ Race Walk

Circle the initials of up to 6 membership categories as described:

AY = Athlete - Youth (under 18); AO = Athlete - Open & Senior; DA =Disabled Athlete; CH = Coach - uncertified; CD = Coach  Developmental certified; C1 = Coach -Level 1 certified; C2 = Coach - Level 2 certified; C3 = Coach - Level 3 certified; PA = Parent; OF = Official - uncertified; OA = Official - Association certified; ON = Official - National certified; OM = Official - Master certified; AD = Administrator; CO = Contributing Member

DATE OF APPLICATION:___________________________

READ AND SIGN
By my signature below, I, a prospective member of USA Track & Field, agree to abide by the applicable USATF Bylaws, Operating Regulations and Rules of Competition for my level(s) and category(ies) of membership. _____________________________________________________________________________
SIGNATURE & DATE (if under 18, parent/guardian must sign instead of athlete)

____ Check here if you DO NOT want your address to be used as part of a running-related direct mail list.

Enclosed is my tax deductible contribution to the ____ Local Association ___National Teams ____Training Centers ____ Other - describe __________________________________________________________
in the amount of ___ $10 ___ $25 ___$50 ___$100 ___ $500 ___ other

Membership Fees:

FEES
$__________ Contribution

__________ Membership

$__________ Total amt. enclosed

Send this completed application with a self-addressed stamped envelope and a check or money order written to
PA/USATF to: Pacific Association/USATF, 120 Ponderosa Ct., Folsom, CA 95630