Family Membership Application

USJA
21 North Union Boulevard,
Colorado Springs, Colorado 80909.
Feel free to call us (719)633-7750, Fax (719)633-4041 for additional donations or to join.
Or print and mail this form.
For more information Email us at usja@usja-judo.org

Family Members: 3 4 5 6 7
Membership Fee: $100.50 $123.50 $141.00 $157.00 $166.50

First Member Information
Name
Street address
Address (cont.)
City State/Province
Zip/Postal code Country
Date of birth Male Female
Home Phone Work Phone
E-mail
New Member
Renewal		 If Renewal, Member
Number		 Jr ( Younger than 17)
Sr ( 17 and older )
Primary Art Studied:
 Rank
 Did USJA
Promote you?		 Yes No

Family Member 2
Name: Age:
Birth Day: Male Female
New Renewal ( If Renewal Member Number: )
Art: Rank: Date of Rank:

Family Member 3
Name: Age:
Birth Day: Male Female
New Renewal ( If Renewal Member Number: )
Art: Rank: Date of Rank:

Family Member 4
Name: Age:
Birth Day: Male Female
New Renewal ( If Renewal Member Number: )
Art: Rank: Date of Rank:

Family Member 5
Name: Age:
Birth Day: Male Female
New Renewal ( If Renewal Member Number: )
Art: Rank: Date of Rank:

Family Member 6
Name: Age:
Birth Day: Male Female
New Renewal ( If Renewal Member Number: )
Art: Rank: Date of Rank:

Family Member 7
Name: Age:
Birth Day: Male Female
New Renewal ( If Renewal Member Number: )
Art: Rank: Date of Rank:

Your Coach:
Name
Club
Street address
Address (cont.)
City
State/Province Zip/Postal code Country
E-mail

Any promotion made by other than the USJA, requires a copy of the promotion
certificate be sent to the USJA for that rank to be recognized by the USJA
Enter additional arts, ranks and any other pertinent info below:

Family Members: 3 4 5 6 7
Membership Fee: $100.50 $123.50 $141.00 $157.00 $166.50

Method of Payment:

Credit Card Number:

Expiration Date: -- mm/dd/yy

Name (as appears on card):
Membership will not be effective until payment received and confirmed.

Mail cards to: Individual Coach

Copyright USJA, 1996.
Last revised: September 24, 1997