NORTHWEST ASSOCIATION FOR BLIND ATHLETES

ONLINE MEMBERSHIP FORM

Please fill out the following form, than follow the link on the next page to pay & process your membership fees.

Name

Address

City

State/Province

Zip/Postal Code

Work Phone

Mobile Phone

Home Phone

E-mail

Date of Birth

Sex Male Female

Membership Type:

Vision Class

B1 (none)
B2 (20/600+)
B3 (20/200-20/400)
B4 (20/70-20/200)

N/A - Volunteer

By selecting Agree below this I herby release the Northwest Association for Blind Athletes (NWABA) from any harm that may come to said name above in practice, competition or any other event relating to Northwest Association for Blind Athletes. I also give NWABA the right to copyright any publication, pictures, and or video clips of myself, without written consent or notice

Agree Disagree

*Name*
*Address*
*City*
*State/Province*
*Zip/Postal Code*
*Work Phone*
Mobile *Phone*
*Home Phone*
*E-mail*
*Date of Birth*
*Sex*	Male Female