N.H.P.A.

MEMBERSHIP APPLICATION

LOUISIANA STATE HORSESHOE PITCHERS ASSOCIATION

“2010 NHPA Card”

State and National Dues (Jan-01 thru Dec-31)

Membership Cards will not be issued unless the Liability Release is signed and dated.

To All LSHPA Members & Prospective Members:

Lost cards shall be reported to the LSHPA Sec./Treas., Jack Atchley

Name:­________________________________________________________________

Address:___________________________E-Mail Address:___________________

City: _________________________State:____________ZIP:________________

Phone: (_____)__________________Date Of Birth:______/______/_________

Latest N.H.P.A. Sanction Number:____________________State:___________

Club or Area Affiliation-------:_____________________________________

/ / Adult Male 40’                             / / Adult Female

/ / Adult Male Less than 40’           / / Junior Female

/ / Junior Male

ONE (1) YEAR - State & National Dues:

.(Adult: National $15.00: Insurance $2.00: State $5.00) $22.00

.(Junior: National $3.00: Insurance $2.00: State $2.00) $7.00

Please include Check or Money Order payable to LSHPA and;

                                                       Mail To---->LSHPA

                                                          % Jack Atchley

                                                         917 Franklin Ave.

                                                        Harahan, LA 70123

                                                  Participant Liability Release

In consideration of participation in such activity, I hereby waive, release, and forever

discharge the National Horseshoe Pitchers Association, all officers, employees, agents

and servants of the afore stated organizations and all fellow participants in any and

all sanctioned leagues and sanctioned tournaments in Louisiana for the year indicated

above, for any and all action, causes of actions, damage, loss or injury which I may suffer

as a consequence of participating in any of these afore stated sanctioned events.

_____________________________________                   _____________________________

Signature (or Legal Guardian for Junior):                        Date