Please print clearly:                                     Date: _________
NAME: ___________________________________________ BIRTHDATE: ___/___/___   M/F:____
ADDRESS: ___________________________________ CITY/STATE/ZIP: ______________________

HOME PHONE: (    )_________-__________   BUSINESS PHONE: (    )_________-__________

EMAIL ADDRESS:_____________________________________________________________________
New Membership: ______   Renewal: _______

Membership Plan:(check One) _______ Single ($15.00)     _______ 5 Year ($75.00)
                            _______ Family ($20.00)	_______ 5 Year ($100.00)
			    _______ 65+ ($5.00)	        _______ 5 Year 65+ ($25.00)
			    _______ 65+ Family ($8.00)  _______ 5 Year 65+ Family ($40.00)
                            _______ 30 Year Paid Member

Check if willing to volunteer at club races/events ______
Club Membership 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 Road Runners Club of America, the NORTH MEDFORD CLUB 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.

  ____________________________________________________________    (OFFICE USE ONLY)
  Signature                                                         AMT PAID: _______
                                                                    HAS CARD: _______
  ____________________________________________________________    NEEDS CARD: _______
  Parent's signature (If under 18 yrs)

  If Family Membership please list:

    NAMES:  __________________________________________________    D.O.B. ___/___/____

            __________________________________________________           ___/___/____

Pay at any club race or make a check out to North Medford Club and mail to:
                             Deb Fontaine
                             786 Elm St
                             Leominster, MA 01453