Is this a New Membership (yes) _____ or a Renewal Membership (yes) _____

Type of Membership (Circle One):     Individual ($25)    Family ($35)

Last Name: ____________________  First Name:____________________ MI:___

Nickname: ____________________  DOB: _______________

Street Address: _______________________________________ Unit: _________

City: _________________________ State: ______________ ZIP Code: ________

Home Phone: ______________________  Cell Phone: _______________________

Work Phone: ______________________ Occupation: ________________________

Email Address: ______________________________________________________

Emergency Contact 1:_____________________________ Phone: ______________

Emergency Contact 2:_____________________________ Phone: ______________

If you circled Family, list other members and ages:

Name: __________________ Age: ____  Name: __________________ Age: ____

Name: __________________ Age: ____  Name: __________________ Age: ____

Name: __________________ Age: ____  Name: __________________ Age: ____

Amount Enclosed: $_______ Make check/money order payable to: Jersey Shore Tri Club

PLEASE SIGN APPLICATION AND WAIVER (BELOW) AND RETURN TO:

JERSEY SHORE TRI CLUB
205 UNION AVENUE
PO BOX 70
BRIELLE, NJ 08730

Jersey Shore Triathlon Club Waiver and Hold Harmless Agreement

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT (“AGREEMENT”)

IN CONSIDERATION of acceptance of this entry or of my being permitted to take part in any event of which the Jersey Shore Triathlon Club (a/k/a JSTC, Jersey Shore Tri Club) is associated with, I, for myself, my heirs, executors, administrator, successors and assigns, waive, release and discharge all claims for damages resulting from death, personal injury or property damage which I may have, or which may hereafter accrue to me as a result of my participation in this event. I understand this release is intended to discharge and release, in advance, the Jersey Shore Triathlon Club, its members and their respective agents, officers, officials, servants and representatives, and any involved municipalities and their respective agents and employees form and against any and all liability arising out of or connected in any way with my participation in the event even though that liability may arise out of negligence or carelessness on the part of the persons or entities mentioned above.

I understand that serious accidents occur during bicycling, swimming, running, and related activities. I further understand that participants in such events occasionally sustain serious personal injury, death and/or property damage as a consequence of that participation. For example, and for the purposes of example only, I am aware that a bicycle may impact another and that the rider may fall and be injured as a result, a swimmer may sustain injury in the open water by a fishing boat, or slip on a pool deck, a runner may trip over debris and sustain injury, and that being present at an event where people participate in athletic events, those people may collide with others. Nevertheless, knowing the risks of participating or being present during a swimming, bicycling, running, or related activity, I, for myself, my heirs, executor, administrators, successors and assigns hereby agree to assume those risks and to release and hold harmless all of the persons or entities mentioned above who, through their negligence or carelessness, might otherwise be liable to me for damages.

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS. I AM OF AT LEAST 18 YEARS OF AGE AND AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN MYSELF AND THE JERSEY SHORE TRIATHLON CLUB AND SIGN IT OF MY OWN FREE WILL. PRIOR TO THIS AGREEMENT’S EXECUTION I MAY CONSULT WITH AN ATTORNEY. FURTHER, I ACKNOWLEDGE THAT BY SIGNING THIS AGREEMENT I MAY BE SURRENDERING CERTAIN LEGAL RIGHTS.

Print Name____________________________________________________________

Signature____________________________________________Date______________

Family “Others” Name____________________________________________________

Signature____________________________________________Date_______________

Family “Others” Name____________________________________________________

Signature____________________________________________Date_______________

Under 18 Family member name_____________________________________________

Print name of Guardian____________________________________________________

Signature of Guardian__________________________________Date_______________

Under 18 Family member name_____________________________________________

Print name of Guardian____________________________________________________

Signature of Guardian__________________________________Date_______________

Under 18 Family member name_____________________________________________

Print name of Guardian____________________________________________________

Signature of Guardian__________________________________Date_______________