2018 ACA Membership Form
                                 ========================

           
           Please print form on your printer, fill it out completely and send it along 
           with your payment by US mail to:

           Allegheny Cycling Association
           PO Box 7044
           Pittsburgh, PA 15212


           ACA memberships are valid on a calendar year basis (January 1-December 31).     
           All ACA memberships expire on December 31.  

          
           Name:      ________________________________________________________________

           Address:   ________________________________________________________________

                      ________________________________________________________________ 

           City:      __________________________  State: ____   Zip Code: ____________

           Phone:     _______________________________ 

           Race Age:  ________________________________
           (As of 12/31/2017) 
           								         
           Email:     _________________________________________________________________

           USAC License Number:  ______________________________________________________

           USAC Cat:   Pro__   Cat 1__   Cat 2__   Cat 3__   Cat 4__   Cat 5__   None__

           Team:      _________________________________________________________________

           Other Club Affiliation: ____________________________________________________ 
               (Freddie Fu Cycling, etc.)

           Medical Insurance: _________________________________________________________

           Person to Call in Case of Emergency: _______________________________________

           Phone:     _______________________________ 

           Cell:      _______________________________ 

           Membership:    Individual $30 per year ____         Family $50 per year ____

           Additional Family Members:   _______________________________________________

                                        _______________________________________________

                                        _______________________________________________

           Comments:    _______________________________________________________________

                        _______________________________________________________________

                        _______________________________________________________________

                        _______________________________________________________________

                        _______________________________________________________________

                        _______________________________________________________________

                        _______________________________________________________________