MEMBERSHIP APPLICATION

Please fill out the following form to join the LPA.

Members First Name

Email Address

Members Last Name

Date of Birth

Address

City

State

Postal Code

Cell Phone

Sign-up for text updates

Yes

No

Is the member under 18 years of age?

No

Yes

Name & Phone Number of Parent / Gaurdian

USPA Membership #

Outdoor Handicap

Arena Handicap

Have your playing privileges ever been revoked? If no, leave blank. If yes, please explain below:

Please select your Membership:

Full Player Member

Social Member

Youth Member

Student Member

Professional Member (2+ Handicap)

Ligonier Polo Association

Tax ID/EIN: 85-1558158