Printable Membership Form
Using This Form
Please type in the following information requested below, print out the form, and mail it in with a check for $30 per Adult Membership and $10 per Associate Junior Membership*. If you prefer, you can print out the form without first filling it in and write in the requested information with a pen or pencil. * - Junior Lifeguard Members Must register with their Local Agency/Chapter.
First Name:
Last Name:
Telephone:
Email:
Street:
City:
State:
Country:
Postal Code:
Employing Agency
(professional and alumni members)


USLA Chapter


USLA Chapter (if not listed above)


USLA Region
Select One:

Membership Category


Status


Membership Number (if known)
Credit Card Information
Name on the Card:
Credit Card Type:
Credit Card #:
Exp. Date:   
Only if different from above
Billing Street:
Billing City:
Billing State:
Billing Country:
Billing Postal Code:
Print out this form and return it with Credit Card Information or a Check Payable to:
USLA Membership
PO Box 322
Avon-by-the-Sea, NJ 07717