American Water Polo Individual Membership Form
This form is used by coaches, referees, athletes, families, and parents.
Coaches registering their clubs must use the Club Registration Form

First Name				Last Name
Street
City			State		Zip
Email
Primary Ph					Home Work Cell (circle one)
Secondary Phone					Home Work Cell (circle one)
Date of Birth
Membership Type (check all that apply)
$40	Senior Athlete (23 or older)		$30	Scholastic Athlete (22 or younger)
Free	Coach or Referee		$25	Limited*
$35	Contributor/Parent		$75	Family Plan
*The Limited Membership is available to athletes currently registered with USWP. Individuals must show proof of membership with their application. This membership does not provide any benefits other than insurance coverage for the competitive events.
If choosing Family Plan, list the names of the additional immediate family members
Name		Date of Birth				Shirt Size
Name		Date of Birth				Shirt Size
Name		Date of Birth				Shirt Size
Name		Date of Birth				Shirt Size
Shirt Size (Please circle one)
Adult XXL				Adult Sm/Yth Lg
Adult XL				Yth M
Adult Large				Yth Sm
Adult Med/Yth XL
Club Name					If not affiliated with a club, check the box to the right
Coaches registering ten or more athletes will be eligible to receive an annual reward. For example, AWP would provide rewards for two coaches in a club with 20 athletes.
Total Amount Enclosed					$
Checks should be made payable to American Water Polo and sent to:
AWP, 320 West 5th Street, Bridgeport, PA 19405