Southern Connecticut Cycle Club, 2010 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 ($25) _ 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,