Abe's Striders Racewalking Club
FIRST NAME_________________________LAST NAME_______________________
ADDRESS__________________________CITY________________________ZIP_____
PHONES_____________ _____________ ____________
(Home) (Work) (Cell)
E-MAIL_______________________________________ DATE OF BIRTH__________
I recognize and acknowledge that racewalking is a vigorous physical activity and that there are certain risks of injury. I agree to assume the full risks of any injuries, including death, damages or loss which I may sustain as a result of participating in any manner, in any and all activities connected with or associated with the Abe’s Striders Racewalking Club. In consideration of my decision to participate in Abe’s Striders Racewalking Club activities, I hereby, for myself, my heirs, executors, administrators, and assigns waive and release any and all rights and claim for damages I may hereafter have against the City of Springfield, Springfield Park District, Abe’s Striders Racewalking Club and it’s members, officers, leaders, organizers, sponsors, officials, their representatives, successors and assigns for any and all injuries I may suffer by reason of my participation in Abe’s Striders Club activities. I further attest and certify that I am mentally and physically fit to participate in all of the Club activities.
Signed___________________________________ Date__________________________
Membership fees (Circle one) (All members must be 18 or over)
$20 Individual (New member) $25 Family (New members)
$10 Individual (Renewing member) $15 Family (Renewing members)
Please make checks payable to Abe’s Striders Racewalking Club and mail to: