MEMBERSHIP APPLICATION FORM

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Primary Phone Number*

Secondary Phone Number

E-mail*

Do you wish to receive WIBCA emails?

Yes

Date of Birth*

Age Group*

17 years and under18 - 64 years65 years and over

Calculated Age

Gender*

Do you wish to register additional members from the same household?*

Please enter the information for each additional family member being registered.

	First Name	Last Name	Date of Birth (yyyy/mm/dd)	Gender	Email Address
1
2
3
4
5
6
7
8
9

ANNUAL MEMBERSHIP FEES*

YOUTH

$ FreeCAD Quantity

ADULTPlease enter a short description.

$30.00CAD Quantity

STUDENTPlease enter a short description.

$20.00CAD Quantity

SENIORPlease enter a short description.

$20.00CAD Quantity

FAMILYMembers of one household.

$70.00CAD Quantity

Total

$0.00CAD

You will receive an invoice by email within two (2) business days.

Do you wish to become a WIBCA volunteer?*

Skill Set / Area(s) of Interest

Availability

DISCLAIMER

WIBCA reserves the right to use any photograph/video taken at any event sponsored by WIBCA, without the expressed written permission of those included within the photograph/video. WIBCA may use the photograph/video in publications or other media material produced, used or contracted by WIBCA including but not limited to: brochures, newspapers, websites, etc.

To ensure the privacy of individuals and children, images will not be identified using full names or personal identifying information without written approval from the photographed subject, parent or legal guardian.

A person attending a WIBCA event who does not wish to have their image recorded for distribution should make their wishes known to the photographer, and/or the event organizer(s).

Any person or organization not affiliated with WIBCA may not use, copy, alter or modify WIBCA photographs, graphics, videography or other, similar reproductions or recordings without the advance written permission of an authorized designee from WIBCA.

Initials*

Please enter your initials in the box above.

Date*

Date

Comments