2009 Nationals Individual Registration: Jumper Information

* Required

First Name:	* Legal Name Only
Last Name:	* Legal Name Only
Middle Initial:
USPA Member Number:	Full USPA membership is required to compete. Join USPA Online
USPA Membership Expiration:	mm/dd/yy Should be no earlier than 10/25/09 Lifetime members use any date beyond 10/25/09
USPA license:	Type: Number:
Birthdate:	* mm/dd/yy Minimum age to compete: 18 years
Gender:	*
EMail:	* (this will be your username for logging in later)
Password:	*
Retype Password:	*
Address:	*
City:	*
State:	*
Zip/Postal Code:	*
Phone:	*
Country of Residence:	*
Country of citizenship:	*
Are you a U.S. Citizen or holder of Resident Alien Card I-551 card or I-551 passport stamp?	Yes No * PLEASE CHECK ONE
Emergency Contact Name:	*
Emergency Contact Phone:	*
Medical Conditions:	* (allergies, infirmities, etc.; if none, type "none")
Last Repack Date:	* mm/dd/yy You can log in and update this later if needed
Health Insurance Carrier:
Health Insurance Policy Number:
Home Dropzone:
Hometown Newspaper:
Year of First Jump:	yyyy
Skydiving Specialty:
Occupation:
T-shirt size: