PINOY HARLEY RIDERS CLUB
Membership Form and Waiver/Release Agreement

Member Name: _______________________________                          Member No. ________________
Address: _____________________________________
City: ________________________________             State: ____________ Zip: _______
Phone Number: (Home) _____________________   Cell) ________________

Would you like your phone number to be published in our “Member's only” page?

                                        YES                          NO

E-mail: ____________________
Date of Birth: _________________
Motorcycle Model / Year: ______________________
Insurance Co. _______________________ Policy No. _______________ Expiration Date: _______________

 

In Case of Emergency:

Contact Name:  ___________________________________            Phone Number: _______________________

WAIVER OF RIGHTS

I hereby consent and agree to waive all rights and benefits arising out of any State Statute that would limit and/or negate the coverage and scope of this release and Indemnification Agreement including, but not limited to, the provisions of Section 1542 of the California Code.

RELEASE OF LIABILITY

I agree that the sponsoring club, Pinoy Harley Riders Club (PHRC), and its officers, members, representatives, and agents shall not be liable or responsible for damage to property or any injury to persons including myself during any event or activity even when the damage or injury is caused by neglect.

I fully understand and hereby agree that all PHRC members and their guests voluntarily participate at their own risk in all PHRC activities / events, and likewise assume all risks of injury and damages that may arise thereof during such activities / events.

I understand that this means I agree not to take any legal action against PHRC or any of its members for any damage to property or injury to persons including myself as a result of or in connection with any PHRC activities or events.

Member Signature: ________________________                 Witness: ________________________
                                                                                                                         (PHRC Officer)
Date: _______________________

                                                Do not write below this line

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Initial Membership Fee: $ ___________       ($25.00 – One-time fee for new members only)                        

Annual Dues: $ __________                           ($25.00 – Due beginning January current year)
Penalty: $ __________                                     ($15.00 – Penalty for late renewal.  After March 31^st)

 

Balance due $ ___________