FWTC Membership Application

Name:__________________________ Date of Birth____/____/____ Sex______

Address:_________________________________________ Home Phone_______

City/State/Zip:_____________________________________Work Phone________

E-mail address:____________________________

Occupation:_____________________________Business Affiliation:________________

Type of Membership: Single:_____ Family:_____ New Member:_____ Renewal:______

Family Members:
Spouse:_________________________________Birthdate:_____________Sex_________

Children:________________________________Birthdate:_____________Sex_________

_______________________________________Birthdate:_____________Sex_________

Make checks to:

Fort Wayne Track Club,
PO Box 11703,
Fort Wayne IN 46860-1703

ANNUAL MEMBERSHIP DUES: January 1 - December 31

New Members: first year only $12
Members under 21: $12
Family rates: $4 for ea. add'l family member ($8 - max)

New Members: If you join during the year, you pay as follows:

100% - Jan-Mar (1st Qtr)
  75% - Apr-Jun  (2nd Qtr)
  50% - Jul-Sep  (3rd Qtr)
  25% - Oct-Dec (4th Qtr)

The Fort Wayne Track Club has obtained an insurance policy through the Road Runners Club of America which gives coverage for various events. Through this insurance we are covered for weekly runs, picnics, socials, and volunteers at races and other club functions. Please sign a waiver if you have not already done so. The waiver will be kept on file.

CLUB MEMBERSHIP APPLICATION WAIVER

I agree for myself, and any other person named on this application, that: I know that running and volunteering to work in club races are potentially hazardous activities. I should not enter and run in club activities unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the run. I assume all risks associated with running and volunteering to work in club races 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 course, all such risks being known and appreciated by me. Having read this waiver and knowing these facts, and in consideration of your acceptance of my application for membership, I, for myself and anyone entitled to act on my behalf, waive and release the Road Runners Club of America, Fort Wayne Track Club, and all sponsors, their representatives and successors, from all claims or liabilities of any kind arising out of my participation in these club activities even though that liability may arise out of negligence or carelessness on the part of the persons named in this waiver. I grant permission to all the foregoing to use any photographs, motion pictures, recordings, or any other record for any legitimate purpose. I understand and will abide by the guidelines that bicycles, skateboards, baby joggers, roller skates or blades, animals, and radio headsets are not allowed in club races.

PRIMARY MEMBER
SIGNATURE:______________________________________Date:____________

PARENT SIGNATURE:______________________________________Date:____________
(if under age 18)