New York State Ski Racing Association -
Nordic, Inc
2004 - 2005 Membership Application
Each
individual family member must fill out a separate form. All family
members must
use the same mailing address.
|__| Renewal - NYSSRA Number |__|__|__|__| |__| New
Last Name___________________ First___________ MI_____
Street Address_________________________ Town__________ State ____ Zip+4 ______-____
Phone
(______)__________________________
Sex: M F
Date of Birth
____/____/____
e-mail address
(optional)
____________________________________
PLEASE INDICATE: I would
like to receive my newsletter (check one)
via: |__| regular
mail (paper) |__| e-mail
only.
The
newsletter will be
posted to the website. E-mail notices will be sent to those who
request
it.
AGE DIVISION: (check
one): |__| Youth
(BKYSL) |__|
Scholastic (high school) |__|
Open |__| Masters
INTERESTS: |__|Biathlon |__|Cross
Country |__|Jumping |__|Nordic
Combined |__|Ski
Orienteering |__|Telemark
Each member must complete the waiver and release of liability below.
In consideration
for the
rights and privileges associated with membership in the New York State
Ski
Racing Association - Nordic, Inc. I acknowledge and agree to be
bound by the following:
1.
Identification of Risks. I understand that
participation in
any skiing activity, including but not limited to, preparation for,
participation in, and coaching of activities in cross country ski
competitions
and clinics, involve risk of serious injury, including permanent
disability,
death and other losses, due to inaction's or negligence of myself or
others.
2.
Assumption of the
Risk. I
agree that I
am responsible for my safety while participating in activities
associated with
NYSSRA - Nordic, Inc., and that such responsibility includes
participation
only; a) when I am both physically and psychologically repaired to
participate
safely, b) after fully familiarizing myself with the venue before
beginning the
activity, and c) while using the equipment of a type and condition
reasonably
necessary to safely participate. I assume all risk connected with
responsibility for any injury or loss connected with my participation.
3.
Waiver. Aware
of the risks and willing to
assume them, I hereby waive, release and agree to hold harmless the New
York
State Ski Racing Association - Nordic, Inc., its affiliates,
subsidiaries,
officers, directors, employees, agents, coaches, trainers, doctors,
officials,
event organizers or sponsors (Released Parties) from any and all claims
by me
for any liability, injury, loss or damage in any way connected with my
participation in activities associated with NYSSRA - Nordic, Inc.,
except where
caused by the gross negligence or willful or wanton misconduct of any
of the
Released Parties. I intend for this waiver and release to also apply to
any
relatives, personal representatives, heirs, beneficiaries, next of kin
or
assigns who may pursue any legal action or claim on my behalf.
4.
Insurance.
I currently have, and agree to
maintain throughout the time that I train and compete, valid and
sufficient
medical and accident insurance. I understand that this is my sole
responsibility and release all persons and entitles from providing this
coverage for me.
Signature:______________________________
Printed Name:__________________________________ Date _____________
For Members of
Minor Age:
This is to certify
that, as
parent/legal guardian of this above named minor, I do hereby
acknowledge and
consent to his/her agreement to be bound by each of the terms and
conditions
identified above.
Parent/Guardian
Signature:____________________________
Parent/Guardian Printed Name:_______________________ Date _____________
Remittance:
$___________
MEMBERSHIP
DUES:
YOUTH (BKYSL, age 13
or
younger) $15 all year;
INDIVIDUAL $20 by
December 1;
$25 after;
FAMILY $40 by
December 1; $45
after.
Make checks
payable to
NYSSRA - Nordic, Inc. and mail to: NYSSRA - Nordic, Inc., PO Box 90,
Clifton
Park, N Y 12065.