British Columbia Blind Sports and Recreation Association
Membership form - April 1, 2013 to March 31, 2014

___ New Member  ___ Renewing Member                            Link back to Member page 
___ Athlete - $15 annual membership fee
            CNIB Registration number: ____________
            Sight Class: ___ B1    ___ B2  ___ B3
___ Supporting Member - $5 annual membership fee
           If you are a coach, NCCP #: __________________

Last Name: ___________________ First Name: _____________________

Street Address: _______________________________________________

City/Town: _________________ Province: _____ Postal Code: _________

Telephone: Home (_____) _____________ Work (_____) _____________

Cellular: (_____) _______________ E-mail: _________________________________

Date of birth (DD/MM/YY): ____/____/____ Gender: ___ Female      ___ Male

Media Release
I, the undersigned, authorize BC Blind Sports & Recreation Association to take and use photographs and/or video footage of my person and to use my name in website and other publications.

Signature of member :________________________________ Date: _______________
(or parent/guardian if a minor)

Emergency Contact Information
Last Name: ___________________ First Name: _____________________

Relationship: ____________ Telephone: Home (_____) ______________

Alternate phone: (_____) _________________

Sports of Interest
___ Athletics    ___ Curling     ___ Dragon Boating     ___ Goalball     ___ Golf 

 ___ Hockey    ___ Judo    ___ Lawn Bowls    ___ Powerlifting   ___ Showdown   

___ Swimming   ___ Tandem Cycling   ___ Wrestling    ___ Other: ________________

Preferred Communications Format    ___ Braille   ___ E-mail  ___ Print

Membership in BC Blind Sports and Recreation Association includes membership in the Canadian Blind Sports Association.