Use Legal Name

First _____________________________ Middle ______________________ Last _______________________________________

Street Address____________________________________________ City ______________________ State ______ Zip _________

City of Birth ________________________ Country of Birth ______________________ State of Birth _________________________

Application Date ____________________ Work Phone/Ext_______________________ Home Phone _________________________

Email Address (Required) _________________________________________________ Fax Number __________________________

Date of Birth (MM/DD/YYYY)  ____/____/______  Gender  Male __  Female __               Cell Number __________________________

Do you have Health & Accident Insurance?   Yes  __ NO __  Club Name (if known) __________________________________________ 

Sport Code (circle one) BA (Boys Basketball) BW (Boys Basketball)  BL (Baseball)  Club Number (if known) ________________________

Check Primary Program   ___ Youth Program if you work with ages 1-20   ____  Adult Program if you work with ages 21-99

By authorizing payment of my annual membership dues, I certify that: 1) I have never been convicted of any sex offense nor felony; or, if so,
I must apply for membership (and receive approval) through the AAU National Office; and, 2) this application is correct in every material
aspect, including but not limited to my (street) address and birth date.  the  Applicant agrees to be bound the AAU Code, including all AAU
Policies, which are available for review on the AAU Web site at www.aausports.org. Note: Parent/Guardian signature if member is under 18 yrs old.

__________________________  ___________    _________________________  _____________
Member's Signature                         Date                    Parent/Guardian Signature              Date

AAU Membership Year is September 1 to August 31