User account

*** After completing this information, you will received an email with instructions to pay your membership dues online. Membership will not be complete until payment is received. If this is a family application, please register each individual but only one payment will be required.

Account information

Username: *

Spaces are allowed; punctuation is not allowed except for periods, hyphens, and underscores.

E-mail address: *

A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.

Locations

Location #1

Location name:

e.g. a place of business, venue, meeting point

Street:

Additional:

City:

State/Province:

Postal code:

Country:

Phone number:

Location #2

Location name:

e.g. a place of business, venue, meeting point

Street:

Additional:

City:

State/Province:

Postal code:

Country:

Phone number:

Emergency Contact

Emergency Contact: *

Please enter the full name of your emergency contact

Emergency Contact Cell Phone:

Emergency Contact Home Phone:

Emergency Contact Work Phone:

Emergency Contact Notes:

Please enter any other helpful information such as additional contacts, allergies, blood type, etc

Profile

First Name: *

Last Name: *

Nickname:

Birthday:

Please enter your birthday

Cell Phone:

Home Phone:

Work Phone:

USAT License #:

Enter your USAT license #

Shirt Size:

Why did you join the Landis Tri Club?:

Feel free to share why you are joining the club, your goals, aspirations, etc

Word verification: * Type the characters you see in this picture.

(verify using audio)

Type the characters you see in the picture above; if you can't read them, submit the form and a new image will be generated. Not case sensitive.

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