JEFFERSON COUNTY SPORTS AUTHORITY

P O BOX 2184

MT VERNON, ILLINOIS 62864

Membership Application

Please Print Clearly

Name:_________________________________________________________________________

Address:_______________________________________________________________________

City:_________________________________________ State: ______ Zip: ____________

Telephone Number Home: __________________ Work: _______________________

Email Address: _________________________________________ Date of Birth: ____________

I am interested in the following sports: (circle all that apply)

Baseball Basketball Tackle Football Girls Softball Other_____________

I am interested in participating in the following: (circle all that apply)

Head Coach Assistant Coach Team Sponsorship Field Sponsorship Volunteer

*****************************************************************************

Jefferson County Sports Authority Use Membership Number: ____________

Payment Type: Cash Check #________ Member Name:_______________________

Secretary __________________________ Date: _________________

Treasurer __________________________ Date: _________________

*****************************************************************************

JEFFERSON COUNTY SPORTS AUTHORITY

P O BOX 2184

MT VERNON, ILLINOIS 62864

Receipt

I, ______________________________________________ have paid $_______ Dollars to the

(Applicants Name)

undersigned J C S A member as payment of my annual membership dues.

________________________________________ Date: ________________

J. C. S. A. Member

Revised 07/2003