2012-2013 Membership Form

2012-2013 Membership Form All fields are required.
Club Sport Team:
First Name:
Last Name:
Birth Date:
Student W Number:
Year in School:		FreshmanSophomoreJuniorSenior
Semester Hours:		Full Time 12+ HoursPart Time 6-11 Hours
Address:
City:
State, Zip:
Phone, Email:
Emergency Contact Information
First Name:
Last Name:
Address:
City:
State, Zip:
Phone, Email:
Personal Medical Insurance
Do you have medical insurance?		YesNo

I authorize Campus Recreation and the University to notify my Emergency contact/parents/guardian in case of an emergency. I verify that all the information given on this form is current and correct to the best of my knowledge.