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Individual & Family Membership Application for Pacific Northwest Outrigger Canoe Association members only.

✶RENEWAL ☐ YES

☐ NO

✶REQUIRED INFORMATION

✶MEMBERSHIP TYPE (Check One) ☐ GOLD

Lifetime

$500

☐ SILVER Adult* 3 Years ☐ BRONZE Adult* Annual

$100 $40

☐ JUNIOR** Annual



$25

☐ FAMILY*** Annual



$75

* Adults are considered 18 years of age at time of renewal **Under 18 years of age only ***Max 2 adults per household

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DONATION FORM (Optional) ☐ $50 ☐ $100 ☐ $500 ☐ $1000

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☐ GENERAL CONTRIBUTION $ ☐ DISCIPLINE $ ☐ SPECIAL PROJECT $

✶USA C/K MEMBER # (if Renewal): ✶BIRTH DATE: MI:

✶FIRST: ✶LAST: ✶GENDER:

☐ MALE

☐ FEMALE

✶ADDRESS: ✶CITY: ✶STATE: ✶ZIP: ✶PHONE HOME: PHONE CELL: PHONE WORK: ✶EMAIL:

✶TOTAL

CREDIT CARD INFORMATION

✶PAYMENT METHOD (Check One) ☐ VISA ☐ MC ☐ AMEX ☐ DISCOVER ☐ CHECK (payable to USACK) ☐ CASH ☐ MONEY ORDER

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✶NAME ON CREDIT CARD: ✶CREDIT CARD #: ✶EXP DATE:

✶SECURITY CODE:

TOTAL TO BE CHARGED ON CREDIT CARD:

MAILING ADDRESS 601 East Blvd. Charlotte, NC 28203 P 704.348.4330 F 704.348.4418 www.usack.org

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✶EMERGENCY CONTACT EMERG CONTACT: EMERG CONTACT PHONE:

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Individual & Family Membership Application for Pacific Northwest Outrigger Canoe Association members only. ✶MEMBER CLASSIFICATION

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(Check all that apply)

FOR FAMILY MEMBERSHIPS ONLY (Provide name and birth date. Attach list of additional juniors, if any.)

☐ ATHLETE ☐ FAMILY/FRIEND ☐ OFFICIAL ☐ CLUB ADMIN ☐ COACH ☐ VOLUNTEER ☐ RACE ORGANIZER ☐ DONOR

ADULT:

NATIONAL OFFICE STAFF

JUNIOR:

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JOSEPH JACOBI Chief Executive Officer 404.510.9066

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JUNIOR: JUNIOR: JUNIOR:

✶CLASSIFICATION ☐ FLATWATER SPRINT ☐ WHITEWATER SLALOM ☐ CANOE/KAYAK POLO

GERALD BABAO Operations & Membership Director 704.348.4330

☐ MARATHON ☐ WILDWATER ☐ CANOE SAILING ☑ OUTRIGGER ☐ FREESTYLE

OKLAHOMA CITY OFFICE

☐ DRAGON BOAT ☐ STAND UP PADDLE BOARD

725 S. Lincoln Blvd. Oklahoma City, OK 73129 P 405.552.404 ext 4504 www.usack.org

(Must CIRCLE ONE primary area of interest AND CHECK ALL other areas of interest.)

CHARLOTTE OFFICE

✶MEMBER CLUB (if applicable):

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601 East Boulevard Charlotte, NC 28203 P 704.348.4330 F 704.348.4418 www.usack.org

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☐ SURFSKI

☐ RAFTING

Circled choice will determine which discipline you may vote in for elections (only adult members are eligible to vote.)

✶MEMBER SIGNATURE:

DATE:

Approved by (Office Use Only):

DATE:

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USA C/K 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 contact 704.348.4330. ABOUT USA CANOE/KAYAK USA Canoe/Kayak (USA C/K), member of the United States Olympic Committee, is a non-profit membership organization promoting canoe and kayak racing in the United States. USA C/K, based in Oklahoma City, Oklahoma is the national governing body for the Olympic sports of Flatwater Sprint and Whitewater Slalom and official U.S. federation of the International Canoe Federation. Other paddling sports sanctioned by USA C/K include Canoe Sailing, Marathon, Freestyle, Wildwater, Polo, Outrigger, and Dragon Boat.

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