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2016 Cyclonaut Multisport Membership Application
Name _______________________________D.O.B.(is a must) ___________________
Address______________________________________________ Sex: M F
City __________________________________ State __________ Zip______________
Phone # Home__________________Cell________________Work________________
Email_______________________________________________________
(Is a must if you want to be kept posted on workouts, races, parties, etc.)
USAT # ________________
Dues Amount: $30
(21 and under are exempt from dues)
Make checks payable to: Cyclonaut Multisport
and mail to Cyclonaut Multisport 56 Ellerton St., Chicopee, Ma. 01020
This form must be signed and forwarded to address above for liability insurance reasons.
Liability Waiver:
I HEREBY ASSUME THE RISKS OF PARTICIPATING IN ALL Cyclonaut Multisport (the “Club”) FUNCTIONS OF EVERY KIND. I acknowledge that Club events are an extreme test of a person’s physical and mental limits and carry with them the potential for death, serious injury, and property loss. I certify that I am in good health and I am physically fit; I have sufficiently trained for participation in such events and have not been advised otherwise by a qualified medical person; and I suffer from no physical impairment which would limit my participation in any Club athletic or social function. I acknowledge that my statements on this Acknowledgement Waiver and Release from Liability (“AWRL“) are being accepted by the Club and are being relied on by the collective organizations of USA Triathlon and USA Cycling (Organizations) and the Club and its organizers and administrators in permitting me to participate in any organized Club function. In consideration for allowing me to become a Club member and allowing me to participate in organized Club functions I hereby irrevocably take the following action for myself, my executors, administrators, heirs, next of kin, successors and assigns: a) I AGREE to abide by the Competitive Rules adopted by the Organizations, including the Medical Control Rules, as they may be amended from time to time, and I acknowledge that my Club membership may be revoked or suspended for violation of the Competitive Rules; b) I WAIVE, RELEASE, AND DISCHARGE from any and all claims or liabilities for death, personal injury, property damage, theft, damages, or loss of any kind, which arise out of or relate to my membership in the Club, my participation in, or my traveling to and from any Club athletic or social function, THE FOLLOWING PERSONS OR ENTITIES: the Club., Club Board Members, Club members, Club sponsors, Club attorneys, volunteers, and the officers, directors, employees, representatives and agents of any of the above; c) I AGREE NOT TO SUE any of the persons or entities mentioned above for any of the claims or liabilities that I have waived, released or discharged herein except in cases of gross negligence or intentional torts; and d:) I AGREE TO INDEMNIFY, DEFEND, AND HOLD HARMLESS the persons or entities mentioned above from all damages, costs, and expenses including attorney fees against any lawsuit or threatened legal action brought by any third party arising out of or related to my membership in the Club, my participation in, or my traveling to and from any Club athletic or social function. By signing below, I hereby authorize the Club to include my name in the newsletter and on the website. I also grant the Club express permission to use photographs of myself in the Club newsletter, Club website, or promotional materials and for submissions to newspaper articles and to Club sponsors. In the event of any dispute arising hereunder, the same shall be submitted to a Court of competent jurisdiction in Springfield, Massachusetts, and in all events the laws of the State of Massachusetts shall govern this agreement. I HEREBY AFFIRM THAT I AM EIGHTEEN (18) YEARS OF AGE OR OLDER, I HAVE READ THIS DOCUMENT, AND I UNDERSTANDITS CONTENTS. Applicants under 18 years of age must their legal guardian read, understand, and sign this AWRL. Signing this waiver gives the club the right to add your name to the FIRM grand prix series annual roster.
Name _____________________________Signature_______________________________ Date____________