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American Water Polo Individual Membership Form
 This form is used by coaches, referees, athletes, families, and parents.
Coaches registering their clubs must use the Club Registration Form

First Name   Last Name    
Street       
City    State   Zip    
Email       
Primary Ph      Home Work Cell (circle one)
Secondary Phone     Home Work Cell (circle one)
Date of Birth        
Membership Type (check all that apply)
$40 Senior Athlete (23 or older)      $30

Scholastic Athlete
(22 or younger)

   
Free Coach or Referee   $25 Limited*  
$35 Contributor/Parent    $75 Family Plan  
*The Limited Membership is available to athletes currently registered with USWP. Individuals must show proof of membership with their application. This membership does not provide any benefits other than insurance coverage for the competitive events.
If choosing Family Plan, list the names of the additional immediate family members
Name   Date of Birth   Shirt Size  
Name   Date of Birth   Shirt Size  
Name   Date of Birth   Shirt Size  
Name   Date of Birth   Shirt Size  
Shirt Size (Please circle one)   
Adult XXL
Adult Sm/Yth Lg
Adult XL
Yth M
Adult Large
Yth Sm
Adult Med/Yth XL
Club Name      If not affiliated with a club, check the box to the right  
Coaches registering ten or more athletes will be eligible to receive an annual reward. For example, AWP would provide rewards for two coaches in a club with 20 athletes.
Total Amount Enclosed $
Checks should be made payable to American Water Polo and sent to:
AWP, 320 West 5th Street, Bridgeport, PA 19405