First Name (*)

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Last Name (*)

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Date of Birth (*)

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Mailing Address (*)

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City (*)

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State (*)
AlabamaAlaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam 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 Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
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Zip Code

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Home Phone

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Cell Phone

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Email (*)

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Local Address

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Local Phone

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Are you a Veteran of the Armed Services
Yes
No

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What branch and when?

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Commitment Level
I will commit to 20 days during the 2010-2011 Season.
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What is your occupation?

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Who is your employer?

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What clubs, boards, associations or other affiliations do you have?

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Would you be willing to help with (check all that apply)
Event Planning
Fundraising
Marketing and outreach
Newsletter
Grant Writing
Race Team
Equipment

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What is your t-shirt size:
SM
M
L
XL
XXL

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Emergency Contact Information

Name (*)

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Relationship (*)

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Address

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City (*)

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State (*)
AlabamaAlaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam 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 Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming
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Zip Code

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Home Phone (*)

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Cell Phone (*)

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Work Phone

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Snowsports Coach Information

Number of Seasons with NE Disabled Sports Program

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Uniform Jacket Number (if applicable)

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Name to be put on your name tag

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What is your home town?

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PSIA/AASI or other certification level (if applicable)

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Current or expired?
Current
Expired

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Are you interested in pursuing your PSIA/AASI certification or your next level in certification?
Yes
No

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Expires

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DSUSA Membership Information

Membership Level
Individual ($75)
Family ($125)*

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Please make checks payable to "NE Disabled Sports"

*Please list family members participating in the family membership. (Families include spouse and children under 18.)

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Please send your DSUSA membership dues to the NE Disabled Sports Center: NE Disabled Sports-Coaches Registration, PO Box 26, Lincoln, NH 03251