USABDA INDIVIDUAL MEMBERSHIP APPLICATION

   I affirm that I am an Amateur dancer.
   I will support the alms and objective of USA Dance and the Olympic movement
  Name_________________Date of Birth_________________Signature_________________
  Name_________________Date of Birth_________________Signature_________________
  Address: No & Street_________________________________________________________
  City_________________________State______________________Zip__________________
  Telephone (Home)_______________________Telephone (Work)______________________
  Fax________________________Email______________________
  How are you willing to help USA Dance?
  _____________________________________________________________________________
  _____________________________________________________________________________
  Chapter______________________________________________________________________            
  Occupations__________________________________________________________________
  Hobbies______________________________________________________________________
  __Recreational   __Competitor   __Am Style   __International  __Pro-Am
  Donations are tax-deductible.
  This form may be used by two persons residing at the same address.
  Please print clearly or type.
                                                     
  Send Application and a check payable to USA Dance to:
  Peg Johnston, Membership Director
  PO Box 4
  Valrico, Florida 33595
  813-685-1656
                 Membership Category (See Previous Page)
  Ballroom Dancer                        x $35 =$________
	Dances for enjoyment and works to improve but does  
	not compete. Selection of this category is optional. 
  Social Adult Dancer                    x $25 =$________
	Enjoys and appreciates the physical, mental, and 
	social benefits of ballroom dancing.
  Social Youth Dancer                    x $10 =$________
	A social dancer under the age of 19.
  Social Dance Teacher                   x $50 =$________
	An individual who is engaged in the teaching of social
	dance who does not compete as a professional and does
	not instruct those who will be competing in USA Dance Events.
  Adult DanceSport Athlete               x $60 =$________
	A competitive dancer who is age 19 or above.
  Student DanceSport Athlete             x $20 =$________
	A competitive dancer who is age of 19 or above but below 
	age 35 and is enrolled in school full time.
  Minor DanceSport Athlete               x $15 =$________
	A competitive dancer who is below the age of 19.
  Professional DanceSport Athlete        x $65 =$________
	A competitve dancer who declares him or herself as a
	professional.
  Dancesport Professional                x $70 =$________
	An individual who serves in an official capacity in the
	field of DanceSport and/or ballroom dance.
  DanceSport: Special Olympics Athlete   x $10 =$________
	Qualifies for participating in Special Olympics
	competitions only.
  DanceSport:Unified Sports Partner      x $25 =$________
	Dance Partner of Special Olympis Athlete - for 
	participating in Special Olympics only.
  Other Member (specify)                        $________
  Voluntary Contributions                       $________
                               Total Submitted  $________