Membership Application

TDI Judiciary Membership Application 2010-2011

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Name*:

Email Address*:

Street Address*:

City*:

State*:

ZIP*:

Date of Birth (DD/MM/YYYY):*

Home Phone*:

Cell Phone*:

Work Phone*:

What is the best way to reach you (via cell/home/email,etc)? *

TDI Judiciary Member Since*:

Years Experience Judging*:

Current profession*:

What organizations do you have personal experience competing or judging within?* (click all that apply):

Nametags are re-issued every three (3) years and are updated yearly with stickers that are affixed to the nametag. Replacement tags are $10 each.

If you are an existing member in need of a replacement nametag this year please

mark the box below

Other (Please List)

Conflict of Interest Disclosure Statement:* (choose one)

I have never personally been a team member, parent of a team member, coach, choreographer, teacher, or employer of a spirit based team in Illinois within the past 3 years

I HAVE personally been a team member, parent of a team member, coach, choreographer, teacher, or employer of a spirit based team in Illinois within the past 3 years and I have disclosed them below:

Name of School

Role (Coach, Choreographer, Member,Parent, etc) Years Affiliated

Note: Failure to disclose a potential conflict of interest could result in suspension of judging privileges and/or membership in TDI Judiciary Association.