Membership Application

Membership: Do you agree to the Terms of Membership YES NO Member First Name: Member Last Name: Street Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip Code: - Zip Suffix County Lake, IL Cook, IL McHenry, IL DuPage, IL Will, IL Kensoha, WI Milwaukee, WI Waukesha, WI Racine, WI Lake, IN Other Primary Phone: Home Mobile Other Work Alternate Phone: Home Mobile Other Work Email: Email 2: Birth Date: / / Ethnicity Black/African American American Indian or Alaska Native Asian Hispanic or Latino Native Hawaiian or Other Pacific Islander White Other Gender: Female Male Non Conforming Disability Amputee- Lower Extremity Amputee- Upper Extremity Cerebral Palsy/TBI Orthopedic Multiple Sclerosis Muscular Dystrophy Spina Bifida Spinal Cord Injury- Para Spinal Cord Injury- Quad Stroke Visually Impaired/Blind Other Able Bodied Military Veteran? YES - Pre 9/11 Era Yes Post 9/11 Era No Please describe any critical health issues that are relevant to physical activity participation (pressure sores, seizures etc)