8.9.10. PRSR 02-18-1998 - Laserfiche WebLink

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• AMERICAN BICYCLE ASSOCIATION P.O. Box 718, Chandler,Arizona 85244, (602) 961-1903 APPLICATION FOR MEMBERSHIP • I do hereby make application for membership to the American Bicycle Association.I also agree to comply with all rules and regulations for all activities and understand that I am fully responsible for my actions.I understand that my mem- bership will be valid for a 12 month period from the date joined and is renewable each year. Today's Date ❑Boy ❑ Girl Name(Please Print) Address City State Zip Phone( ) Date of Birth Age Credit my membership to Track CHECK APPROPRIATE BOXES ❑ BMX MEMBERSHIP ❑ RENEWAL:Serial# (Stub must be attached) TEMPORARY CONVERSION..$20 ❑ FIRST FAMILY MEMBER $35 ❑ SECOND FAMILY MEMBER $33 Serial#of 1st Family Member ❑ THIRD&ADDITIONAL FAMILY MEMBERS $31 Serial#of 2nd Family Member ❑ NOVICE ❑ INTERMEDIATE ❑ EXPERT ❑ NOVICE GIRLS ❑GIRLS ❑ STREET STOCK We must have serial numbers of previous family members to allow the discounted fees.If not provided,fee of new member is $35.Family memberships only receive one copy of the American BMXer monthly. ❑ PRO MEMBERSHIP $60 PROS ONLY ❑ PRO CRUISER MEMBERSHIP $60 Social Security# ❑ CRUISER MEMBERSHIP $35 • ❑ CRUISER MEMBERSHIP w/20"MEMBERSHIP $25 20"Serial# ❑ASSOCIATE MEMBERSHIP $16 (Parent,bike shop owner,etc.Includes subscription to American BMXer) WAIVER OF CLAIM-MEDICAL RELEASE-ADDITIONAL CONDITIONS I.The applicant warrants that he is either an adult in the state where he lives or that the person signing as his representative is his custodial parent or duly appointed legal guardian. 2.The applicant and his representative recognize that BMX is a sport where there exists the potential for personal injury.In consideration for the participation in all ABA BMX activities, the applicant hereby agrees to release the ABA,its officers,employees,agents and sponsors from all liability(hereafter collectively"ABA").including liability based on the negligent or intentional acts by the ABA for damages,loss or injuries,either to applicant's person or his property which may be sustained while engaged in any activity conducted by or in connection with the applicant's ABA membership. 3.The applicant and his representative hereby agree to indemnify and hold the ABA harmless from any damages,claims,demands,causes of action or suits,including those based on the negligence or intentional acts of the ABA.which arise out of damage,loss or injury to either the applicant or his property made by the applicant or anyone on the applicant's behalf: 4.The applicant and his representative agree that.in the event that the applicant requires medical or surgical treatment while under the supervision of ABA personnel in connection with any sponsored activity or trip,such ABA personnel may authorize medical treatment for the applicant.The applicant and his representative agree to pay for all medical,hospital,or other expenses which the applicant may incur as a result of such treatment. 5.I also hereby grant to the ABA and its employees,agents,and assigns the right to photograph me and use my picture,silhouette,and other reproductions of my physical likeness as it may appear and any still camera photograph or videotape.The applicant also expressly grants to the ABA,its employees,agents and assigns the right to use any photograph,silhouette, or other reproduction of the applicant's physical likeness in connection with any television,theatrical or print exhibition•advertising or publicizing of ABA or any of its activies or programs. The applicant further gives ABA the right to reproduce in any manner whatsoever the applicant's voice or any instrumental or musical or other sound effect produced by the applicant. • j APPLICANT REPRESENTATIVE(PARENT OR GUARDIAN) Enclosed is my check for$ Please charge my (3 VISA ❑MasterCard ❑American Express $ Acct.# MC Bank# _ _ _ Expiration Date S2 Charge for use of card per membership APPLICANT MUST READ&SIGN BACK OF FORM(NO EXCEPTIONS) (OVER) THIS IS YOUR TEMPORARY MEMBERSHIP CARD.YOUR PERMANENT CARD WILL ARRIVE BY MAIL. 'you must send a cony of your birth certificate to the ABA offices within 45 days of the above date. Today's Date F:`�ceived of(Name) Amount$ for ❑ BMX MEMBERSHIP Date of Birth ❑NOVICE ❑ INTERMEDIATE ❑ EXPERT ❑NOVICE GIRLS ❑ GIRLS • Age ❑ PRO MEMBERSHIP ❑ PRO CRUISER ❑ CRUISER MEMBERSHIP ❑ASSOCIATE MEMBERSHIP ❑ RENEWAL • SIGNATURE OF TRACK OPERATOR AMERICAiN BICYCLE ASSOCIATION•P.O. Box 718•Chandler,Arizona 85244•(602)961-1903