British Columbia Blind Sports and Recreation Association
Membership form - April 1, 2017 to March 31, 2018

___ 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

__  I consent to receiving information from BC Blind Sports and Recreation Association.
__  I consent to receiving notices from organizations other than BC Blind Sports that may be of interest to members.*you may request to have your name removed at any time.

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.

Please make cheques payable to:
BC Blind Sports and Recreation Association
#170 - 5055 Joyce Street, Vancouver, BC V5R 6B2
Telephone: (604) 325-8638