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
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