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Please print BOTH PAGES, fill out and send in. Dont forget about the transponder #, this is MANDATORY.
_________________________________________________________________________________
PEACE MOTOCROSS ASSOCIATION
Membership/Waiver of Liability & Indemnity Agreement
Revised 2010
Rider’s Full Name: _______________________________ Birthdate (y/m/d) _______________
Address (Complete) _____________________________________________________________
Town/City____________________________________ Postal Code ___________________
Phone No: __________________________ Email Address ______________________________
P.M.A. MEMBERSHIP P.MA. Race No. 1st choice ______
Renewal New 2nd choice _______
TRANSPONDER # __________________
(If you do not have a transponder, you MUST purchase one with your membership.)
CLASSES REGISTERING IN: CLUB YOU ARE JOINING:
(Mark all classes competing in for 2010) (Must mark the Club you wish to join.)
NOTE: Numbers/Background Colors in ( )
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50 cc (4-6 years)
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Fort St. John, BC
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50 cc (7-9 years)
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Taylor, BC
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60 cc (Age 7-11)
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Dawson Creek, BC
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80 cc (Age 7-11)
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(Red/White)
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Grande Prairie, AB
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80 cc (Age 12-16)
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(Black/White)
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Beaverlodge, AB
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Supermini (60-80cc)
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Chetwynd, BC
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Youth (Age 13-24)
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Worsley, AB
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Quad
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Ladies A
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Ladies B
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MEMBERSHIP FEES (Please Mark)
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(Mark one)
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125 Novice
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(Red/White)
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50 cc only
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$ 50.00
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125 Junior
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(Red/Yellow)
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Individual
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$150.00
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125 Intermediate
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(Black/Yellow)
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Family:
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125 Expert
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(Black/White) or
(White/Black)
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1st Member
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$ 150.00
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250 Novice
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(Red/White)
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2nd Member
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$ 125.00
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250 Junior
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(Red/Yellow)
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3rd Member
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$ 100.00
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250 Intermediate
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(Black/Yellow)
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4th Member
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$ 75.00
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250 Expert
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(Black/White) or
(White/Black)
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5th Member
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$ 50.00
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Vet Master (25+)
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Transponder Fee
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$ 230.00
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Vet Junior (25+)
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Membership Fee Enclosed:$____________
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BOTH PAGES OF FORM MUST BE FILLED OUT AND SIGNED AS APPROPRIATE
PEACE MOTOCROSS ASSOCIATION
Membership/Waiver of Liability & Indemnity Agreement
2010
WAIVER OF LIABILITY & INDEMNITY AGREEMENT:
I have read the PMA Rules & Regulations and I, on behalf of myself and entrant(s) and owners(s) of the vehicle herein, agree to be bound by them and by the PMA Rules & Regulations. In consideration of the acceptance of these events or of my being permitted to take part in these events, I on behalf of myself, the entrant(s), and the owners(s), their respective heirs, executors, administrators, successors, and assignees, agree at all time to release, defend, same harmless and keep indemnified the PEACE MOTOCROSS ASSOCIATION, the organizers, and their respective agents, officials, servants, representatives, and affiliates against all actions, claims and suits, whether groundless or otherwise, and from all liabilities, losses, damages, costs, charges, counsel fees, and any other expenses of any nature and character incurred by said bodies, their agent, officials, servants, representatives or affiliates, in respect of death, injury, loss of or damage to my person or property, or to any and all persons and property howsoever caused arising out of or in connection to or occasioned by the negligence of the said bodies, their agents, officials, servants, representatives or affiliates.
YES, “I AGREE TO ALLOW MY CHILD, CHILDREN, OR MY NAME, RACE NUMBER, CLUB & TOWN TO APPEAR ON THE PMA WEBSITE, RADIO OR NEWSPAPER.
NO, “I DO NOT AGREE TO ALLOW MY CHILD, CHILDREN, OR MY NAME, RACE NUMBER, CLUB & TOWN TO APPEAR ON THE PMA WEBSITE, RADIO OR NEWSPAPER.
The undersigned has read and voluntarily signed the release and waiver of liability and indemnity agreement, and further agrees that no oral representations, statements or inducements apart from the foregoing written have been made. I have read this release.
_____________________________ _________________ ______________________
(Signature of Rider) (Date) (Make of Motorcycle)
If signatory is under 18 years of age, parent or guardian’s signature is required and the parent/guardian both on behalf of the child personally adopt in full the covenants of indemnity & waiver of liability detailed above.
__________________________________ ______________________________
(Signature of Parent/Guardian) (Printed Name of Parent/Guardian)
PLEASE CHECK IF YOU WOULD LIKE A RECEIPT ISSUED.
MAKE APPROPRIATE PAYMENT TO:
Peace Motocross Association
RR1 S15 C62
Fort St. John, BC, V1J 4M6
(250) 787-5514
Tammi Doll
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