New Orleans Track Club Membership Application
Annual Memberships
_____ $25.00 Individual Mail to: New Orleans Track Club
_____ $30.00 Family PO Box 52003
_____ $15.00 Senior (over 60) New Orleans, LA 70152-2003
_____ $20.00 Senior (over 60) Family or Fax to: 504-469-9268
_____ $15.00 Youth (17-under)
Credit _____ _____ ___________ ___________ ___________ ___________ ____-____
Card: Visa M/C Account Number Exp Date
____________________________________________________________________ _________
Signature of cardholder Bank Code
MEMBER INFORMATION
____ Runner ____ Walker ____ Wheelchair
Last Name _______________________________ First ______________ Initial _____
Address ____________________________________________________________________
City _______________________________ State ______ Zip Code ____________
Home Phone __________________________ Work Phone _____________________________
Email ____________________________________________________________________
Sex ____Male ____Female Date of Birth _____________________________
FAMILY MEMBERS
Last Name _______________________________ First ______________ Initial _____
Sex ____Male ____Female Date of Birth _____________________________
Last Name _______________________________ First ______________ Initial _____
Sex ____Male ____Female Date of Birth _____________________________
Last Name _______________________________ First ______________ Initial _____
Sex ____Male ____Female Date of Birth _____________________________
OFFICIAL USE ONLY
Membership No ____________ Exp Date _____________ Amt Enclosed ____________
I know that running and volunteering to work in club races are potentially hazardous activities. I should not enter and run in club activities 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/or 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 the acceptance of my application for membership, I, for myself and anyone entitled to act on my behalf, waiver and release the Road Runners Club of America, the New Orleans Track Club and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in these club activities even though that liability arise out of negligence or carelessness on the part of persons named in this waiver.
Signature ______________________________________ Date ________________________ Signature ______________________________________ Date ________________________ (Signature of Parent or Guardian if Entrant is Under 18)
I grant permission to all of the foregoing to use any photographs, motion pictures, recordings, or any other record of the event for any legitimate purpose. I understand that bicycles, skateboards, baby joggers, roller skates or blades, animals, and radio headsets are not allowed in the race and I will abide by this guideline.