2003  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______

                                                                                                                                                                                                             

Please Make checks payable to: Culpeper Road Runners, Inc.    10313 Walker Drive    Culpeper, VA     22701
 

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, Inc. 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, Inc. activities unless medically able and properly trained. I/we assume all risks associated with participating in Culpeper Road Runners, Inc. 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, Inc. and its agents and volunteers from all liability related to Culpeper Road Runners, Inc. activities; I/we will hold harmless and indemnify Culpeper Road Runners, Inc. and its agents and volunteers from all liability, legal actions, debts, claims, and demands of every nature whatsoever that arise of Culpeper Road Runners, Inc. activities. I agree that the information on this application may be published to all Culpeper Road Runners, Inc. 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_________

___________________________________Date_________________DOB_________.......