Individual Membership Application

USA Dance Inc.

NAME(s)

DATE OF BIRTH

SIGNATURE(s)

DATE

MAILING ADDRESS

CITY

STATE

ZIP CODE

HOME PHONE

WORK PHONE

FAX

E-MAIL ADDRESS

MEMBERSHIP CATEGORY   (fees include chapter dues)

ADDITIONAL INFORMATION:

Social Dancer

__ x $35 =

$

Occupation:

Ballroom Dancer

__ x $45 =

$

Champion DanceSport Athlete

__ x $75 =

$

Hobbies:

Adult DanceSport Athlete

__ x $75 =

$

Student DanceSport Athlete, below age of 35

__ x $25 =

$

Please check all applicable below - I am a:

Junior DanceSport Athlete, below age of 19

__ x $15 =

$

     Social Dancer

Social Youth

__ x $10 =

$

     Competitor (American Style)

Associate

__ x $65 =

     Competitor (International Style)

Manager

__ x $65 =

$

     Competitor (Pro/Am)

Trainer

__ x $65 =

$

Proficiency Level (Circle Applicable Level)

Official

__ x $65 =

$

International: Bronze Silver Gold Novice / Pre-Champ / Champion

American: Bronze Silver Gold Novice / Pre-Champ / Champion

Total Membership Fees

$

Total Contributions (as listed on the right):

$

Tax Deductible Contributions: 

Kitsap, Chapter 1025

$

CHECK TOTAL:

Make check payable to

USA Dance Kitsap

$

TV Programs! Videos (National level)

$

Amateur Travel

$

Youth Programs: Chapter or National (Circle)

$

Are you willing to help your USA Dance Chapter as a volunteer? __ Yes __No

College Programs

$

General Fund: Chapter or National (Circle)

$

How are you willing to help?

Setup/Cleanup

Decorations

Dance instruction

Greeter at dances

Publicity

Dance Team

Other:

Make check payable to: USA Dance of Kitsap Peninsula

Please mail application & check to:

               USA Dance, Kitsap

               P.O. Box 3617

               Silverdale, WA 98383