If applicant is under 18 years of age, are MINOR/PARENT RELEASE must be signed and filed with this application. This form must be neatly printed or type and filled out in full. Illegible forms will be rejected.
Kart No.:
Class:
License # Date Issued: Membership Fee $25
Checks Payable to Kate Maille
If you need more membership applications, feel free to photocopy this one.
(FOR OFFICE USE ONLY)
Full Name______________________________________________________________
Adress_________________________________________________________________
City________________________ State____________________ Zip____________
Date of Birth:____________________________Place of birth:_____________________
Employed by:______________________________ Phone ( )____________________
Address:_________________City:________________ State:___________ Zip:_______
Do you have any handicaps or disabilities? Yes ÿ No ÿ If yes, describe on the back of this form and sign it.
Date of last physical exam_______________ Physical Condition____________________
Do you currently have health insurance? Yes ÿ Noÿ If yes, please describe on the back of this form and sign it
Name of insurance company/plan_______________________ Agent________________
Agent’s Phone:__________________ Address
CHECKS PAYABLE TO KATE MAILLE
ADVERTISING RELEASE: The undersigned consents to the use of his/her name before and after relinquishes any right to photos taken in connection with events and consents to the publication or sale of such photos by TTR.
SAFETY RELEASE: I hereby give up all my rights to sue or make any claim against the TURKEY TROT RACEWAY and it’s organizers, promoters, sponsors, and all other persons or organizations conducting or connected with this event for any injury to property or person I may suffer, including crippling injury or death, weather such injury arises while I am preparing or participating in the event or while I am upon the event premises.
I know the risks of danger to myself and my property while participating in the event, and while upon the event premises and relying upon my own judgment and ability, assume all such risks of loss and hereby agree to reimburse all cost to those persons or organizations connected with this event for damages incurred as a result of any injury that I cause or receive.
ARBITRATION: Any dispute, controversy, or claim involving the undersigned member, weather or not relating to this agreement or alleged breach of same, shall be settled in accordance with the existing and/or amended rules and regulations of the association and the undersigned agrees to accept the decision rendered in the process. I understand there will be no refund of membership fees once paid for any reason.
Date:-----------------X Legal Signature_________________________________________
Fee must be paid at time of application. TTR reserves the right to reject this or any application