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California USA Wrestling Membership Form

                                                   +-------------------+
                                                   |   State Use Only  |
_______________________  ________________________  |  USAW Card Number |
First Name                Last Name                |                   |
                                                   |   ______________  |
                                                   +-------------------+
                                          
										  
___________________________________________________
Address



_____________________  _____  ____________   _______________
City                 State  ZIP            Phone



_____ / ____ / ____        Athlete   Coach       Male  Female
Month   Day    Year         
   Date of Birth           (circle one)         (circle one)