River City Rebels Running Club
Renewal and New Member
Application
____ Renewal ____ Name and
Address Changes Indicated Below
Annual Dues: (Check the one that
applies)
____ Individual membership - $25
____ Family membership - $40
____ New Member Application
Annual Dues: (Check the
one that applies)
____ Individual membership - $25
____ Family membership - $40
Pro-rated dues for joining after June 30,
2011
____ Individual
membership - $15
____ Family membership - $25
$ _______ Total Amount Owed (You may pay dues for multiple years if you
wish.)
Name: ___________________________________________________________
Address: _________________________________________________________
City: ________________________________________ State: ___ Zip:
______
Home Phone: _______________ Work: _______________ Cell:_______________
Gender: ___ Birth date (m/d/y): ______________ PA/USATF #: ______________
E-mail Address: _____________________________________________________
(Please attach name, birth date, and gender for all family members who are
joining.)
CLUB MEMBERSHIP APPLICATION WAIVER
I know that running and volunteering to work in club races are potentially
hazardous activities. I should not enter
and run in club activities unless I am medically able and properly
trained. I agree to abide by any decision
of a race official relative to my ability to safely complete the run. I assume all risks associated with running and
volunteering to work in club races including, but not limited to, falls,
contact with other participants, the effects of the weather, including high
heat and/or humidity, the conditions of the road and traffic on the course, all
such risks being known and appreciated by me.
Having read this waiver and knowing these facts, and in consideration of
your acceptance of my application for membership, I, for myself and anyone entitled
to act on my behalf, waive and release the River City Rebels Running Club, USATF,
and all sponsors, their representatives and successors from all claims
or liabilities of any kind arising out of my participation in these club
activities even though that liability may arise out of negligence or
carelessness on the part of the persons named in this waiver.
Signature:
__________________________________ Date:
_____________
Mail application & check
to: