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2013-2014 Membership Form
All fields are required.

Club Sport Team:  
First Name:  
Last Name:  
Birth Date:          
Student W Number:
Year in School:  
Semester 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?  

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.