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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Commintment Level

10 days (Must have volunteered with NE Disabled Sports for three or more consecutive seasons to qualify for 10 day commitment. Pass restrictions apply.)
20 days


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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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PSIA/AASI or other certification level (if applicable)

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Expires

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DSUSA Membership Information

Membership Level

Individual ($75)
Family ($100)*
Donors($100)

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Please make checks payable to "NE Disabled Sports"

*Please list family members participating in the family membership.

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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