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MEMBERSHIP APPLICATION

 

LOUISIANA STATE HORSESHOE PITCHERS ASSOCIATION

“2010 NHPA Card”

 

State and National Dues (Jan-01 thru Dec-31)

(One applicant per-form)

 

Membership Cards will not be issued unless the Liability Release is signed and dated.

 

To All LSHPA Members & Prospective Members:

 

If possible, you will be issued the same card number that you have

previously held. Lost cards shall be reported to the LSHPA Sec./

Treas., Jack Atchley. A replacement card will be issued following

notification of lost card.


Name:­_____________________________________________________________

 

Address:____________________________ E-Mail Address:___________________

 

City: _____________________________ State:____________ ZIP:_____________

 

Phone: (_____)____________________ Cell: (_____)____________________


                    Date Of Birth:______/______/___________

 

Latest N.H.P.A. Sanction Number:______________________ State:_____________

 

Club or Area Affiliation ------ :___________________________________________

 

Adult Male 40’ Adult Female

Adult Male Less than 40’ Junior Female

Junior Male

 

ONE (1) YEAR - State & National Dues:

.(Adult: National $15.00: Insurance $2.00: State $5.00) $22.00

.(Junior: National $3.00: Insurance $2.00: State $2.00) $7.00

 

Please include Check or Money Order payable to LSHPA and;

 

Mail To:

LSHPA

% Jack Atchley

917 Franklin Ave.

Harahan, LA 70123

 

Participant Liability Release

 

In consideration of participation in such activity, I hereby waive, release, and forever

discharge the National Horseshoe Pitchers Association, all officers, employees, agents

and servants of the afore stated organizations and all fellow participants in any and

all sanctioned leagues and sanctioned tournaments in Louisiana for the year 2008, for

any and all action, causes of actions, damage, loss or injury which I may suffer as a

consequence of participating in any of these afore stated sanctioned events.

 

________________________________________

___________________________________

Signature (or Legal Guardian for Junior):

Date

LSHPA Website: http://harahanhorseshoepitchers.com/LSHPAcontacts.htm

NHPA Website: www.horseshoepitching.com