2006 MEMBERSHIP APPLICATION
Check Appropriate affiliation :
________NEW MEMBER __________
RENEWING
Name_______________________________________________________________Birthdate:____________________Male_______Female_______
Address_________________________________________________________________________________________
Phone# Home_________________________________
Work_________________________________ E-mail:____________________________
Membership Categories
(Circle one)
Individual : $10.00 Family: $15.00
Full Time Student: $ 5.00 Sponsor:
$25.00
I am interested in : Races ____ Timing at events____
Helping w/ Newsletter (labeling/stamping/folding etc)_____ Water
Stations at events____ Registration ______ Anywhere you
need me on event day_____
Track 1-2x week___
Being a Race Director for one race_____ Helping org. Children’s runs_____ Being an officer ____
Morning or After 5 p.m. group runs_____ Women's training
runs/walk______
List Additional Family Members
and Birthdays:
1)____________________________________________2)___________________________________
3)____________________________________________4)___________________________________
(Membership release) FOR RUNNERS and VOLUNTEERS
I agree, for myself and any other persons named on this application
that: participation in Culpeper Road Runners, activities, such as races,
group runs, and volunteer work, is potentially hazardous and may result in
personal injury or property loss: I/we will not participate in Culpeper Road
Runners, activities unless medically able and properly trained. I/we
assume all risks associated with participating in Culpeper Road Runners, activities, including, but not limited to falls, contact with other runners
and persons, the affects of weather (particularly heat and humidity),traffic,
and conditions of the roads, trails, and track; I/we release Culpeper Road
Runners, and its agents and volunteers from all liability related to
Culpeper Road Runners, activities; I/we will hold harmless and indemnify
Culpeper Road Runners, and its agents and volunteers from all liability,
legal actions, debts, claims, and demands of every nature whatsoever that
arise of Culpeper Road Runners activities. I agree that the information
on this application may be published to all Culpeper Road Runners,. members,
unless I decline on this application.
Primary Member Signature___________________________________ Date_____________
If under 18, Parent or Guardian must also sign here: ____________________________
Signatures of other family
members:
___________________________________Date
________________DOB_________
___________________________________Date
________________DOB_________