* Applicant Name(s):...................

* Street Address:.......................

*City:....................................

*State:........

Zip:..

*Today's Date:

* Primary Phone Number:............

Cell Phone Number...................

*Email Address:........................

* USHPA Rating:.......................

* USHPA Expiration Date:...........

*USHPA Number:......................

Emergency Contact Name:...........

Emergency Contact Phone:.........

* Type of Application:..................

I acknowledge by clicking the SUBMIT button that I have read, understand, and will abide by the Rainier Paragliding Club by-laws.