(This form is for printing and mailing only)

Name: ______________________________________________

Street: ______________________________________________

City, State, Zip: _______________________________________

Home Phone: (    ) _____-______   Date of Birth: ___________

Email address: _______________

Referred by and reason for joining:_________________________

   New              Renewal          Address Correction

Individual ($25)

Individual ($45)

Family-Couple ($40)*

Family-Couple ($65)*

Junior-Under 18 ($15)

Senior-Over 64 ($15)

Senior-Over 64 ($30)

I know that running and volunteering to work in club races are potentially hazardous activites. I should not enter in club activites 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 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, The Rockland Road Runners Club and all sponsors, their representatives and successors from all claims or liablities 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.

____________________________________________________/__/______

SIGNATURE OF MEMBER(S)

____________________________________________________/__/______

SIGNATURE OF PARENT OR GUARDIAN (if under 18)

Please mail this application to: RRR Membership, Box 132, Congers, NY 10920
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