MEMBERSHIP APPLICATION FORM

MEMBERSHIP APPLICATION FORM
Full Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Primary Phone Number *
Secondary Phone Number
E-mail *
Do you wish to receive WIBCA emails?

Yes
Date of Birth *

Month Day Year
Age Group *

17 years and under 18 - 64 years 65 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
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ANNUAL MEMBERSHIP FEES *
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YOUTH
Free Quantity

ADULT Please enter a short description.
$ 30.00 CAD Quantity

STUDENT Please enter a short description.
$ 20.00 CAD Quantity

SENIOR Please enter a short description.
$ 20.00 CAD Quantity

FAMILY Members of one household.
$ 70.00 CAD Quantity

Total

$ 0.00 CAD
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

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
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. Clear
Date *

Month Day Year
Date
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