2010 Membership Form

(the formatting of the form on this web page isn't the best, but for now if you copy the text below and paste it into MS Word with margins of .6" top/bottom and .3" right/left, it should print legibly on a single page for you)

2010 JOIN/RENEW* MEMBERSHIP FORM

Name: ____________________________________________________________________________________

*Address: _________________________________________________________________________________

*City: _________________________________________________ *State: ________  *Zip: ______________

Email: ________________________________________________ *Work Phone:  ______________________

*Home Phone: _______________________________ *Mobile Phone: ________________________________

*Occupation:_________________________________ *DOB: __________________ (Junior Member if not 18 years of age)

Membership: New Member * *Renewing Member * USAT #: ___________________

(*fields above with an asterisk may be left blank only if a renewing member has no changes/updates to what was supplied last year)

Races Planned for 2010: _____________________________________________________________________

Volunteer Interests: Races * Events * Group Workouts * Tailgates * Other __________________

Waiver of Liability. Please read carefully and sign below: In consideration of my membership in, and any benefits afforded by, Philadelphia Triathlon Club (PTC), I for myself, executors, heirs, next of kin, administrators, and for anyone else who might claim or sue on my behalf, assume any and all risks and associated with my traveling to or from and participation in a PTC activity, event or workout. I hereby waive, release and discharge any and all claims, losses or liabilities for death, personal injury, partial or permanent disability, property damage, medical or hospital bills, theft or damage of any kind, including without limitation any economic losses, which may arise out of or relate to my participation in or traveling to or from a PTC activity, event or workout that may arise now or in the future against PTC, and its organizers, directors, members, officers, sponsors, volunteers and any other individuals or entities associated with PTC. I also grant permission to PTC and its organizers, directors, members, officers, sponsors, volunteers and any other individual or person associated with PTC to photograph, videotape and record me while participating in a PTC activity, event or workout for the use and publication in promotional materials, advertisement and reports. I further authorize the use and release of my name and age and other directory information. I also grant my permission for a doctor and/or nurse to take remedial action in case of an emergency, and that I assume all expenses in the event of an accident, illness or other incapacity, regardless of whether I have authorized such expenses. By signing below I: (i) agree to and accept the terms and conditions of this Waiver of Liability; (ii) will respect and adhere to all club requirements, benefits, sponsorships, pro-deals, etc.; and (iii) remain a loyal PTC member throughout this enlisted year.

Signature: ______________________________________________ Date: ___________________________

______________________________________________ (Parent or legal guardian must sign for junior member)

Dues $45.00. Submit form and check payable to: Philadelphia Triathlon Club 
Attn: Membership

PO Box 29126

Philadelphia, PA 19127