P. O. Box 844
Mansfield, OH 44901-0844
E-Mail – Diane Hammett, President – email@example.com
MID-OHIO BIKERS 2016 MEMBERSHIP APPLICATION
Membership entitles you to the monthly newsletter, calendar, participation in all club-sponsored events and voting privileges at the November meeting. Membership runs from April 1 through March 31. Membership applications are accepted throughout the year; however membership fees for the following year are due on April 1. Please return payment and application form to address above.
2016 CLUB OFFICERS
President: Diane Hammett 419-566-3782 Rec. Secretary: Mark Brady 419-310-0629
Vice Pres.: Shawn Gatton 419-961-3093 Fall-N-Leaf Terry White
Treasurer: Terry White 419-545-3946 Membership Roster: Diane Hammett 419-566-3782
Newsletter: Mark Brady 419-310-0629
Today’s Date Birth date (optional)
month & day
City, State, Zip Code
Home Telephone No. (include area code)
Cell Phone No. (include area code)
When are you most available for bike rides? mornings afternoons evenings weekends
What best describes your riding preference? Bike trail flat roads flat to rolling rolling hills hilly
Distance you prefer to travel on a ‘typical’ ride. 10-20mi. 25-35mi. 40-50mi. 55-70mi. 75-100mi.
Dues: $15.00 Individual (Yearly) $25 Family (Yearly)
Names of other family members: Spouse Birthday
(Birth date is optional) Children
HELMETS ARE REQUIRED ON ALL CLUB RIDES.
Use of head phones is prohibited on all club rides. (A ‘club ride’ is 2 or more club members)
Please sign the waiver on the reverse side. If “Family” membership includes two adults, both need to sign. This is required by the insurance carrier and will enable the person(s) listed to participate in any club activity for the current year without having to sign another waiver.
Monthly meetings are held at 7:00 p.m. on the third Tuesday of the month, excluding January and February, at the Gorman Nature Center, 2295 Lexington Avenue, Mansfield. November and December meeting dates and place are announced.
LEAGUE OF AMERICAN WHEELMEN d/b/a LEAGUE OF AMERICAN BICYCLISTS ("LAB") RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AND PARENTAL CONSENT AGREEMENT ("AGREEMENT")
IN CONSIDERATION of being permitted to participate in any way in MID OHIO BIKERS ("Club") sponsored Bicycling Activities ("Activity") I, for myself, my personal representatives, assigns, heirs, and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of Bicycling Activities and that I am qualified, in good health, and in proper physical condition to participate in such Activity. I further acknowledge that the Activity will be conducted over public roads and facilities open to the public during the Activity and upon which the hazards of traveling are to be expected. I further agree and warrant that if, at any time, I believe conditions to be unsafe, I will immediately discontinue further participation in the Activity.
2. FULLY UNDERSTAND that (a@ BICYCLING ACTIVITIES 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 Activity, the condition in which the Activity 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 Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the Club, the LAB, their respective administrators, directors, agents, officers, members, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owners and leasors of premises on which the Activity 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 OPERATIONS; AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or anyone on my behalf, makes a claim against any of the Releases, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost which any may incur as the result of such claim.
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 ANY 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.
1. PRINTED NAME PARTICIPANT:
2. PRINTED NAME PARTICIPANT:
Street City State Zip
1. PARTICIPANT'S SIGNATURE (only if age 18 or over):
2. PARTICIPANT'S SIGNATURE (only if age 18 or over):
DATE: __________________________________ PHONE:
AND 1, THE MINOR'S PARENT AND/OR LEGAL GUARDIAN, UNDERSTAND THE NATURE OF BICYCLING ACTIVITIES AND THE MINOR'S EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED, IN GOOD HEALTH, AND IN PROPER PHYSICAL CONDITION TO PARTICIPATE IN SUCH ACTIVITY. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS EACH OF THE RELEASEES FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON THE MINOR'S ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS AND FURTHER AGREE THAT IF, DESPITE THIS RELEASE, 1, THE MINOR, OR ANYONE ON THE MINOR'S BEHALF MAKES A CLAIM AGAINST ANY OF THE RELEASEES NAMED ABOVE, I WILL IDEMINFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE, OR COST ANY MAY INCUR AS THE RESULT OF ANY SUCH CLAIM.
PRINTED NAME OF PARENT/GUARDIAN:
Street City State Zip
PARENT/GUARDIAN SIGNATURE (only if participant is under the age of 18):
liability release.doc FORM NO. AMSP-WR-LAB MINOR (8/2001)