Page 34 - WCA-2023-09

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* access it on line. You MUST
□ Life Membership $30 provide valid email address
□ Senior Life Membership (Age 60+) $300
$500

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).
4. Musicians and Disc Jockeys, except clowns/magicians who engage
Tractor pulls, Rodeo and roping events, motorized events, in these activities as part of their act.
Mechanical amusement devices, inflatables, rock climb.Bounce 5. Throwing objects (Juggling is acceptable).
Houses, laser tag, sky diving, competition racing. 6. Production Management or Promotions Management for hire.
3. Pyrotechnics, Explosives, Fireworks or similar materials except

□ 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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