Application for Membership in Club South Runners

Mail application with membership waiver and check made payable To:

Club South Runners, P.O. Box 65123, Baton Rouge, LA 70896

Circle One:

New

Renewal

Address Change

Name:__________________________________________________________________

Address:________________________________________________________________

City/State/Zip____________________________________________________________

You may _____ may not _____ publish my (family's) information in the Club South Runners membership directory.

Date:__________________ Phone:(home)_________________ (office)_____________

E-Mail Address:____________________________________________ Birthdate:____________________

Occupation:_____________________________

ANNUAL DUES (CIRCLE ONE) REGULAR $20. STUDENT $10. FAMILY $25* * Family - Individual + $3 for each additional Family Member; not to exceed $30. *

List Names & Ages __________________________________________________________________

__________________________________________________________________

Participation Legal Waiver Please send waiver along with Check for Completed Membership Application I know that running and/or volunteering to work in Club South Runners events are potentially hazardous activities. I should not enter and or run in Club South Runners activities unless I am medically able and properly prepared and/or trained. I agree to abide by any decision of race/event officials relative to my ability to safely compete or assist in this organization's activities. I assume all risks associated with running and/or volunteering to work in Club South Runners events including - but not limited to - falls, contact with other participants, the effects of the weather, including high heat and/or humidity, the conditions of the road and traffic on the coarse, all such risks being known and appreciated by me. Having read this Club South Runners waiver and knowing these facts and in consideration of your acceptance of my application for membership, I, for myself and for anyone entitled to act on my behalf waive and release the Road Runners Club of America, Club South Runners, and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in these Club South Runners' activities, even though the liability may arise out of negligence or carelessness on the part of the persons named in this waiver. I grant permission to all of the foregoing to use any photographs, motion pictures, recording, or any other record of my participation in any Club South Runners event for any legitimate purpose.

Signature ______________________________________________ Date _______________

Parents'/Guardians' Signatures __________________________ Date _______________