Name_______________________________ Date of Birth___________________________________

Street Address______________________________________________________________________

City ______________________________State _______________ Zip _______________________

Work Phone ________________________Home Phone ______________________________________

Work E-mail _______________________Home E-mail _____________________________________

Spouse/Significant Other Name (optional)____________________________________________

Children's Names/Ages (optional)____________________________________________________

Choose one of the following options for class of boat you race:

Laser   Sailboard    505   Other  _______________________________

Tell us a little about your sailing background _____________________________________

____________________________________________________________________________________

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How did you learn about SCRA? ______________________________________________________

Choose one of the following membership options:

Flag Membership (includes entire family) $50 

Full Time Student $30  (please provide name of school and location)

Junior Member (under 18) $30