American Snowsport Education Association-Central

2011-2012 Membership Application

3225 West St. Joseph, Lansing, MI 48917
PH: (517) 327-0601 FAX: (517) 327-3260
info@psia-c.org

NATIONAL ID #:
FULL NAME: kylesearchterm
ADDRESS: snowsport
Street City State Zip

BUSINESS PHONE: MOBILE PHONE:

HOME PHONE: FAX NUMBER:
EMAIL:
PREFERRED METHOD OF CONTACT: Mail Phone Email Other:

DOB: / / GENDER: Male Female

DISCIPLINE: Alpine Snowboard Telemark Cross Country Adaptive

SNOWSPORTS SCHOOL:

MEMBERSHIP TYPE:
If you choose a membership type that requires proof, you must submit proof with payment. Please see the back of
this form for information about the categories and discounts.
Membership Category: Membership Discount: Late Fees:
Add $15.00 if renewing after June 30th
$100.00 Registered Student Discount ($20 Reduction)
$100.00 Certified Central Senior ($10 Reduction) Add $20.00 if renewing after July 31st
$50.00 Alumni National and Central Senior ($20 Reduction)
$100.00 Inactive Active Service Personnel (Dues Waived)

PAYMENT INFORMATION:
Paying by Check # ______ Paying by Credit Card Visa Mastercard AMEX Discover
CC #: Exp Date:
MEMBERSHIP DUES: $
Education Foundation Donor Release
BACK DUES / LATE FEES: $ By checking this box, you are not allowing
Central Division to use your name in public
EDUCATION FOUNDATION DONATION**: $ acknowledgement of your contribution to the
TOTAL PAYMENT TO BE CHARGED: $ Education Foundation.

**The Education Foundation researches new techniques and methodologies of teaching snowsports, develops safety programs for
snowsports, and the development of skiing programs for the handicapped

Signature: Date:
By paying my ASEA-C membership dues I acknowledge that skiing or snowboarding can be a hazardous sport and I hereby release
ASEA-C, the host area and the directors, officers, agents and employees of each from liability for any and all injuries and damages of
whatever nature arising during or in connection with my participation in a ASEA-C event.