8.9.10. PRSR 02-18-1998 - Laserfiche WebLink

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AMERICAN BICYCLE ASSOCIATION P.O. Box 718, Chandler, Arizona 85244 III (602) 961-1903 APPLICATION FOR TRIAL MEMBERSHIP I do hereby make application for membership to the American Bicycle Association.I also agree to comply with all ABA rules and regulations for all activities and understand that I am fully responsble for my actions. I understand that my membership will be valid for a 30 day period from the date joined. Todays Date Expiration Date Name(please print) Address City State Zip Phone( ) Date of Birth Age This a trial membership and may only be used for 30 days for competition.After that,a full ABA membership is required. This may only be used in competition by a new novice rider and ABA points are not included.(Not good at multi-point events).TRIAL MEMBERSHIP-$15.00(includes secondary insurance). WAIVER OF CLAIM -MEDICAL RELEASE In consideration of the participation of the minor child being permitted to particpate in all ABA BMX activities, - I hereby agree to indemnify and hold blameless ABA,its officers,employees or agents from any and all liability from damages,loss or injuries,either to person or property,which the said minor may sustain while engaged in any activity conducted by or in connection with ABA,including but not limited to transportation. I further certify that I have custody or am the legal guardian by court order.I further alledge that the said minor . is physically able to participate in the activity set forth herein.I further agree to reimburse or make good any loss or damages or costs that ABA may have to pay ifany litigation arises on account of any claim made by said minor's behalf. I agree that in the event said minor requires medical or surgical treatment while under the supervision of ABA recreational personnel in connection with any sponsored activity ortrip,such supervisor may authorize treatment.I also agree to pay for all medical,hospital,or other expenses which said minor may incur as a results of such treatment. I also hereby expressly grant to the ABA and its employees,agents and assigns the right to photograph me and use my picture silhouette,and other reproduction of my physical likeness,(As the same may appear in any still camera photographs,and/or video tape productions),and in connnection with exhibition on TV or otherwise,of any video tape and which the same would have been used or incorporated,and also in advertising,exploiting,and/or publicizing of any such video tape,but not limited to television.I further give to said company the right to reproduce in any manner whatsoever any recordations made by said company of my voice and all insrumental,musical or any other sound effect produced by me. Signature of Parent or Guardian • THIS IS THE ONLY MEMBERSHIP CARD YOU WILL RECEIVE. DO NOT LOSE IT. This is a trial membership and may only be used for 30 The ABA member is covered by a secondary medical insurance plan days for competition.After that a full ABA membership that is good while that member is a participant in any ABA sanctioned race or practice.This coverage is good only if the member's primary is required.This may only be used in competition by a insurance.self insuance or health plan does not pay.For more new or novice rider.(Not good at multi-point events). Information contact: r AMERICAN BICYCLE ASSOCIATION P.O.Box 718 Today's Date Chandler,Arizona 85244 (602)961-1903 Expiration Date RIDER:You must get an insurance claim report from the track where the accident happened.Valid through date shown. Nam Address 0 City State Zip Phone( ) Date of Birth Age This membership good only at Signature of Track Operator This stub good for$15.00 credit on Full Membership within 30 days.