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WCA - MEMBERSHIP RENEW

                      WCA Membership Effective For 1 Year from Date Processed by Business Office


        Print form, check the appropriate box(s), then Fax, Email, or Mail form along with payment to the WCA Business Office.
        Membership, and insurance is NOT. auto-renewable. A new form must be submitted every year.   PLEASE PRINT LEGIBLY
        ITEMS WITH * MUST BE FILLED IN OR FORM WILL NOT BE ACCEPTED                       ONLY 1 PERSON PER FORM

        Name (Legal): ░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░   Performance Name: ░░░░░░░░░░░░░░░░░░░░░
        *Address:  ░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░

        *City: ░░░░░░░░░░░░░░░░░░ *State/Province: ░░░░░░░░░░░░░░░░░░░  *Zipcode: ░░░░░░░░░░░░░░░░░
        *Country: ░░░░░░░░░░░░░░░░░░░░░   Phone: ░░░░░░░░░░░░░░░░░░░░░░░░░░░  WCA#: ░░░░░░░░░░░

        Type of Performance: ░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░░ Date of Birth: ░░░░░░░░░░░░░
        Email: ░░░░░░░░░░░@░░░░░░░░░░░░░░░░   I Alley Affiliation (if any): ░░░░░░░░░░░░░░░░░░░░░░░░░░░
             To receive an Electronic Ballot for Annu al Voting
                                                                                                                   Referred By: ░░░░░░░░░░░░░░░░░░░░░░░░░░░░░
                    Please include email address
           MEMBERSHIP                             □ MEMBERSHIP CURRENT - $0                 *Electronic Memberships will
                                                                                            not receive Printed Clowning
        □ Regular Membership (Age 16-59)       $40 □ Senior Membership (Age 60+)             $30  Around Magazine but can
        □ Junior Joey Membership (Age 5-15)    $20  □ Electronic Membership*                       $30  access it on line. You MUST
        □ Life Membership                                  $500 □ Senior Life Membership (Age 60+)   $300  provide valid email address

                              LIABILITY INSURANCE (Optional - US Members Only)
        □  You must check box, sign this form and fill in Type of performance to obtain insurance.
           Cost: $200/year. Effective for 1 Year from processed date.
           You MUST be a member of the World Clown Association and have a US mailing Address to purchase the insurance.

        COVERAGE: This is a Comprehensive General Liability Policy provided by an A-rated insurance company with coverage of $1,000,000 per occurrence/
                 $2,000,000 aggregate per event. Deductible: None The price includes Premium, Brokerage fee and Association handling fee.
         Policy Exclusions: This program is designed for Clowns and Magicians. The following types of performances are NOT ACCEPTABLE:
        1. Hypnosis.                                             “concussion effects”, “flashpots”, and “smokepots” (Flash boxes
        2. Hot Air Balloon Events, Circuses (production), overnight camping   covered up to $5,000).
          Tractor pulls, Rodeo and roping events, motorized events,   4. Musicians and Disc Jockeys, except clowns/magicians who engage
          Mechanical amusement devices, inflatables, rock climb.Bounce   in these activities as part of their act.
          Houses, laser tag, sky diving, competition racing.   5. Throwing objects (Juggling is acceptable).
        3. Pyrotechnics, Explosives, Fireworks or similar materials except   6. Production Management or Promotions Management for hire.

        □ Declined        ABUSE LIABILITY INSURANCE (Optional - US Members Only)
        Coverage is only available at time of purchase of primary liability insurance. It may not be added on later nor be purchased separately. This
        covers liability for actual, alleged, or threatened abuse, molestation, or exploitation civil liability. This coverage excludes cost fines or penalties
        arising out out criminal investigation, or prosecution. For further explanation see official binder online at worldclown.com. If this coverage is
        selected the po/icv will not be processed until a Nationwide background check is submitted to the business office. You may only select one.
        The premium is in addition to the $155 liability premium.
               □ $100,000 per Occurrence/ $500,000 per Event $280              □ $1,000,000 per Occurrence and per Event $450


        Signature: (MANDATORY)

        Payment:  □ CHECK - CHECK#   ░░░░░░░░░░         □ PAID ONLINE           (Check/Money Order must be from US or Canadian Bank)
        CHECKS ONLY!  WE CANNOT ACCEPT CREDIT CARD VIA THIS FORM. IF YOU WISH TO USE A CREDIT CARD PLEASE PAY ONLINE AT WORLDCLOWN.COM

                                        Please send form along with your payment to:
                          World Clown Association, Inc. 6164 Scherr Road,. Berrien Springs, Ml 49103
                  EMAIL: manager@worldclown.net | PHONE: 219-487-5317 | WEBSITE: www.worldclown.com

                                        THIS FORM VALID FOR USE THROUGH MAY 1 ST 2024
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