2021 Atomic Betty Waiver & Contact Info Question Title * 1. Name & Mailing Address Name Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Email Address Phone Number Question Title * 2. What is your age? Under 18 (parent permission needed) 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 or older Question Title * 3. Would you like to listed on the Atomic Betty Club Roster? Yes No Maybe Question Title * 4. Emergency Contact Information Name Phone Number Question Title * 5. Please list any allergies or medical conditions that we need to be aware of and support. Question Title * 6. I agree to keep Atomic Betty Club Codes protected, as these are for paying members. Yes No Does Not Apply (non-paying membery) Question Title * 7. Atomic Betty Club WaiverI have read and agree to the terms listed in the above link. This is also posted on the Atomicbetty.club website. Yes No Question Title * 8. I am a new member to Atomic Betty! Yes No Done