Southern Connecticut Cycle Club, 2007- 8 Season
Membership Application, Renewal, Personal Information Change
Form
The club offers
individual and household membership. The
membership year runs from January 1st to December 31st. If you join on or after October 1st,
your membership will carry over through the next full year. Please complete and return the entire
form.
Release and Waiver of
Liability, Assumption of Risk, and Indemnity Agreement
In
consideration of my application for membership in the Southern Connecticut Cycle
Club ("SCCC") and being permitted to participate in SCCC sponsored
bicycling, hiking or other club event ("Event") I for myself, my
personal representatives, assigns, heirs, and next of kin:
1. Acknowledge,
agree, and represent that I understand the nature of bicycling, hiking or
other club Event and that I am qualified to participate in such Events. I further acknowledge that the Event
will be conducted over public roads and facilities open to the public during
the Event and upon which the hazards of traveling are to be expected. I further agree that if at any time I
believe conditions to be unsafe, I will immediately discontinue further
participation in the Event.
2. Fully understand that: (a) Bicycling, hiking or other Events
involve risks and dangers of serious bodily injury, including permanent
disability, paralysis and death ("Risks"); (b) these Risks and
dangers may be caused by my own actions, or inactions, the actions or
inactions of others participating in the Event, the condition in which the
Event takes place, or the negligence of the "Releasees" named below;
(c) there may be other risks and social and economic losses either not known
to me or not readily foreseeable at this time; and I fully accept and assume
all such risks and all responsibility for losses, costs, and damages I incur
as a result of my participation or that of the minor in the Event.
3. Hereby release, discharge, covenant not to sue, and agree to indemnify
and save hold harmless the SCCC, its respective administrators, directors,
agents, and employees, other participants, any sponsors, advertisers, and if
applicable, owners and leasers of premises on which the Event takes place,
(each considered one of the "Releasees" herein) from all liability,
claims, demands, losses, or damages on my account caused or alleged to be
caused in whole or in part by the negligence of the "Releasees" or
otherwise, including negligent rescue operation.
I
have read this agreement, fully understand its terms, understand that I have
given up substantial rights by signing it and have signed it freely and
without inducement or assurance of any nature and intend it to be a complete
and unconditional release of all liability to the greatest extent allowed by
law and agree that if any portion of this agreement is held to be invalid the
balance, notwithstanding, shall continue in full force and effect. Parent
or Guardian of a Minor: I as parent or guardian of the below named minor,
hereby give my permission for my child or ward to participate in the Event,
and further agree, individually and on behalf of my child or ward, to the
terms of the above.
Signature:
__________________________________________ Date: ______________
Parent Signature (if member is under 18):
______________________________________ Date:______________
Type of Membership: _ Individual ($20) _ e-mail only ($15) _ Household ($35) _ Household e-mail only ($30)
Amount
Enclosed:
$__________
Type: _ New
_ Renewal _ Information Change only
Name: ________________________________ E-mail:
_______________________
Phone (home): ______________
Street:
_______________________________ญญญ_ City: _________________________
State: ______ Zip: _____________
Additional
Household Member -
Name: ___________________________
Signature ____________________________ Date:
_____________
I can help with: _ Leading Rides _ Leading Hikes _
_ Summer Picnic
_ Century Ride
_ X
Country Skiing
_ Newsletter Parties
Include my name, e-mail address, and town on list
available to club members only:
_ Yes _ No
Make checks payable to SCCC and mail
entire form to: SCCC,