West Texas Crawlers Membership Form

Member Information Name: Last:_________________________________First:___________________________ MI: _____

Date of Birth: ___/_____/________ Address: City:_____________ State:____________Zip:_______________ Phone number: (_____) ______-_________ HOME or WORK or CELL (circle one)

Secondary Number: (_____) ______-_________ HOME or WORK or CELL (circle one) Email: _______________________________________________________

Any medical conditions? __________________________________________________________________________________ _______________________________________________________________________________________________________ If you are under the age of 18, have a legal parent or guardian sign below and contact the president confirming that you may participate X_______________________________________ Date: ___/___/___

Emergency Contact Information Name: Last:_________________________________First:___________________________

Address: City:_____________ State:____________Zip:_______________ Phone number: (_____) ______-_________ HOME or WORK or CELL (circle one) Email: _______________________________________________________

Relation/reason to be emergency contact: ___________________________________________ Can this be contacted in the event of an emergency, regardless of time? Yes No

Vehicle Information Make: _______________ Model: _________________________________ Year: ___________ Color: _________________ License Plate Number: ________________________ Insurance? Yes No

How did you hear about the West Texas Crawlers? Facebook Friend Card Other: _______________________________

I am willing to pay the annual fee of $20 to be in WTC: Yes No

I agree to represent the West Texas Crawlers club and its values to and throughout the community. All information above is valid, and I know the capabilities of my vehicle and myself and I am willing to stay within my abilities to prevent danger or harm to myself, my vehicle, and others. X_____________________________________________ Date: ___/___/___

West Texas Crawlers Release and Waiver of Liability and Indemnity Agreement
In consideration of being permitted to participate in any event sponsored, promoted, or directed by the West Texas Crawlers, herein referred to as "WTC", the undersigned, his/her executors, administrators, personal representatives, heirs, and assigns hereby releases and forever discharges WTC, and WTCs officers, directors, promoters, sponsors, employees, and agents from any and all claims of loss or damage including personal injury or death whether or not caused by the negligent act or omission of WTC and/or WTC's officers, directors, promoters, sponsors, employees, and agents while the undersigned is for any purpose participating in, or in route to or from any event sponsored, promoted, or directed by WTC. It is fully understood by each of the undersigned that there is some inherent risk associated with this and subsequent events, including damage to vehicles. In addition, the undersigned agrees to indemnify and hold harmless WTC, and the WTC's officers, directors, promoters, sponsors, employees, and agents from any loss, liability damage, or cost they incur due to such participation by the undersigned, whether caused by WTC, or the WTC's officers, directors, promoters, sponsors, employees, and agents while the undersigned is participating in an event sponsored, promoted, or directed by WTC. Each of the undersigned also agrees to comply with any and all local, county, state and federal laws while participating in, or in route to or from any event sponsored, promoted, or directed by WTC. If a law is broken, neither WTC, nor WTC's officers, directors, promoters, sponsors, employees, and agents will be held liable for the undersigned individual actions. In signing this release, each of the undersigned hereby acknowledges and represents the following: 1. That he or she has read, fully understands, and will comply the foregoing Release and Waiver of Liability and Indemnity Agreement under all circumstances. 2. That he or she shall at all times, while riding in a vehicle participating in an event sponsored, promoted, or directed by WTC will wear his or her respective seat and shoulder belts. 3. That the owner/driver certifies that he/she has inspected this vehicle and same is in good mechanical condition, and is carrying their own automobile insurance (at least liability). 4. That the owner/driver has or will inform himself/herself about this and subsequent events, the trail(s) involved in this and subsequent events, either by prior participation or by investigation into the event and trail(s). THIS WAIVER MUST BE SIGNED BY ALL PARTICIPANTS, RIDERS AND GUESTS. (For a participant under the age of 18 years of age, both parents, the parent with legal custody, or the minor's legal guardian must sign this release) Vehicle________________________________ Owner/Driver_______________________ VIN # (last 8 digits)____________________

Drivers License. No. & State__________________

_____________________________________________________________________________ Driver's Signature Printed Name Date _____________________________________________________________________________ 1st Passenger's Signature Printed Name Date _____________________________________________________________________________ 2nd Passenger's Signature Printed Name Date _____________________________________________________________________________ 3rd Passenger's Signature Printed Name Date