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N.W.P.A. Membership
Application
( Please print clearly and provide complete
information )
* required information
* Name:
____________________________________________________
* Address:
__________________________________________________
* City: __________________ State:
___ Country: _________ Zip: ______
* Home Phone: (_____)
_____-_______ Bus Phone: (____) ____-________
* E-Mail:
____________________________________________________
* Date of Birth: Mo ___ /Da
___ /Yr ___ Age: ____ Male: __ Female: ____
Please Check Desired Membership Level
___ Annual / Player = ($10.oo U.S. Resident )
___ ($15.oo Non U.S. Resident)
___ Life / Player = ($125.oo U.S. Resident )
___ ($130.oo Non U.S. Resident )
____Associate Annual / Non Player = ($10.oo U.S. Resident)
____($15.oo Non U.S. Resident)
___ Associate Life / Non-Player = ($60.oo U.S. Resident)
___ ($65.oo Non U.S. Resident)
Please Describe Your Disability: Para ___ Quad ___ Amputee ___
Other ___ (describe)
_________________
( you may be required to
obtain a letter from your physician )
All players must use a wheelchair
for pool competition and must remain
seated at all times while at the
table.
The N.W.P.A. reserves the right to
reject any application that
is not fully completed or does
not meet our
specifications and also has the
right to suspend any member for rule(s) violation.
Make check or money order payable to: N.W.P.A.
Send to: NWPA, Inc 9651 Halekulani Dr. , Garden Grove, Ca 92841-4911
Set
printer for 1 page
Waiver
For, and in consideration of the National Wheelchair
Poolplayers Association, Inc.
(N.W.P.A.) and its sponsors; for myself and on the behalf of my heirs,
assigns, personal
representatives and next of kin, I hereby release and hold harmless
the National Wheelchair Poolplayers Association, Inc., their officers,
officials, agents and/or employees ("Release's"), with respect to any
and
all such injury, paralysis, dismemberment, disability, death and/or
loss
or damage to person or property, whether caused by the negligence of
the releasees or
otherwise, except that which is the result of gross negligence and/or
wanton misconduct.
I hereby voluntarily agree that my entry, participation or attendance
during an event sanctioned by the N.W.P.A., constitutes permission
to be photographed, filmed and/or voice recorded for the use
in publicity, promotional or media purposes and constitutes a waiver
of any and all claims for compensation from all sponsoring agents.
If acting as a participant, l also agree to pay in full, all Federal,
State and local
taxes that may be due on any money, prizes or gifts won or given to me
during
any N.W.P.A. sanctioned event. I also, hereby agree, to abide by all
of
the rules, regulations and agreement and fully understand its
terms.
I understand that l have given up substantial rights by signing it and
sign
it freely and voluntarily without inducement.
SIGNATURE:___________________________________ DATE:
_______________________________
  
www.nwpainc.org/mbrshp.htm . 
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