CC Riders “High Altitude Member”
(HAM) Application & Liability Release Form
Member Name:
___________________________ ______ __________________________
First
MI Last
Address:___________________________________________________________________________
City:
Home Phone:
_________________________
E-Mail:_________________________________
O.K to add your name
to the “High Altitude Member” website roster? (Y/N)_______
Motorcycle(s)
Year:
_____________________ ________________________
Make:_____________________ ________________________
Model:____________________ ________________________
Engine:____________________ ________________________
Colors:____________________ ________________________
Which Ride did you complete?
____ The five (5)
passes that rose to 10,000 feet elevation or more.
____ The summit of
____ The summit of
____ The Six Pack
Event (6 passes over 10K ft. in one day)
Liability
Release
I (We) agree the sponsoring group, CC
Riders, and the respective officers, directors, employees and agents, as well
as the sponsoring individual of any quest, property owner of any property CC
Riders has permission to use, the ride leader, the rider leader’s team of any
ride in which I (we) may participate, (hereinafter the “Released Parties”),
shall not be liable or responsible for injury to me (us) (including paralysis
or death) or damage to my (our) property during any CC Riders activities even
where the damage or injury is caused by ordinary negligence.
I (We) understand and agree this
release shall be construed in the broadest sense allowed by law and this is a
knowing and intelligent waiver of any and all right which I (we) might have to
the fullest extent allowed by law. I (We) understand and agree all CC
Riders members and guests participate voluntarily and at the individual’s sole
risk in all CC Riders activities and I (we) hereby knowingly and intelligently
agree to assume all risks of injury and damage arising out of or related to
conduct of such activities.
I (We) release, indemnify and
hold harmless the “Released Parties” from any injury or loss to my (our) person
or property which may result from my (our) participation in CC Riders
activities and events, and agree to indemnify the “Released Parties” for any
cost incurred in defending against any action I (we) might bring in violation
of the terms of this release including, but not limited to, costs and
reasonable attorney fees. I (We) further agree to waive all
benefits flowing for any specific state statue now in effect or subsequently
enacted, to the full extent allowed by law, which would negate or limit the
scope of this release and indemnification agreement.
I (We) hereby understand this means I
(we) agree not to sue the “Released Parties” for any injury or damage to myself
(ourselves) or my (our) property resulting from, or in connection with, any CC
Riders activities or events.
I (We) represent to the club I (we)
have had training and/or experience and I (we) attest I (we) am (are) skilled
in the operation of a motorcycle and riding in a group.
By signing this document I (we) certify
I (we) have fully read this Release and completely understand it. I (we)
am (are) not relying on any statements or representations made by the “Released
Parties” and that I (we) knowingly and intelligently execute this release which
shall be effective until revoked in writing by me (us) prior to any injury,
damage or possible cause of action accruing.
Print member
name:__________________________________ Signature:______________________________
Date:___________
Please check all that
apply:
__ $10.00 - HAM patch
(current CC Rider member only)
__ $15.00 - HAM patch
(non-CC Rider member)
__ $3.00 - “2008
5 Passes Elev. 10,000+” rocker
__ $3.00 - “2008
__ $3.00 - “2008 Mt. Evans Elev. 14,264” rocker
__ $3.00 -
“2008 6 in 1 – Six Pack Event” rocker
__ $3.00 - “
$______ . 00 = your
total payment to receive patches and rockers.
Mail photographs and this
application/liability release with your cash or check payable to:
CC Riders (HAM)
C/O Gary Cox
Parker, CO.
80138-7174
Thank you for your participation
and we welcome you as a “HIGH ALTITUDE MEMBER”
* Your photographs
will be mailed back you, along with the patches and rockers.
********************************************************************************************
For Club Business
Only
Cash ____ Cash Amount
_______
Check No. _______
Check Amount _______
Date received:
_________________
Date Pictures,
Patch(s) and Rocker(s) mailed to member
__________________