Mach One SRS Team
Membership Application Form
A USA Canoe/Kayak organization with Junior Olympic Development Program
A calendar Year Team
2014
Jan. 1 through Dec. 31
Name
________________________Date ___________________
New Member
Address ________________________
Sponsor: ___________________________________
________________________
City, St, Zip
_____________________
Home Phone
Cell ________
___________________
________________
(person)
Cell ________
Original Membership *
$100
$_______
Ongoing Membership-Paddling ** $75
$_______
Non-paddler Membership Support $30
$_______
Multiple/Family discount (less $10/person)
________________
* Includes Basic Paddling Course
** Includes use of boats, any & all paddle equipment,
coaching, use of Sunnyside course.
Note: Special rates for family in financial need.
(person)
Birthday for Juniors ________________
Check No. _______ Amount: $________
emails _________________________________
_________________________________
Active, paddling members also need USACK membership, separately obtained.
USACK membership covers liability either with an event or a full year membership.
Return to David A. Kurtz, 118 E. South Hills Ave., St. College, PA 16801
Persons covered by this application
(with youth ages):
814-237-7727
USA C/K No.
(for renewal)
___ Leadership of Youth Team
________________________________ _________ ___ Help general cruising program
___ Assist Youth Team
________________________________ _________
__ at home __ at away races
___ Trip leaders program/training
________________________________ _________ ___ Safety program
Members of Mach One Team, Inc. are covered for all activities (cruising, racing, training) for liability
claims by participation in USA Canoe/Kayak Organization Plan. Under this plan all paddling members
must be members of USAC/K which costs on an annual basis $55 for adult, and $25 for individual
juniors. New participants of activities (cruises or volunteers helping to run an event) are covered by a
USA/CK Event Membership which costs $10 for the event.
[Please fill out and sign the reverse side]
December 31, 2013
mach1\forms\applicform.2014
WAIVER AND RELEASE OF LIABILITY
For participation in any Mach One, USA Canoe/Kayak (National Paddling Committee, Inc. dba USA Canoe/Kayak sports
and recreation program), American Canoe Association, Inc., and AAU Junior Olympic athletic/sports program and related
events and activities, the undersigned, his or her personal representatives, assigns, heirs, and next of kin:
1. Agree(s) (with parents if a minor) acknowledge, and represent that I understand the nature of Paddlesports and related
Activities and that I am qualified, in good health, in proper physical condition to participate in such Activity and willingly
agree to comply with the stated and customary terms and conditions of participation. I further agree that prior to
participating, I have inspected the facilities, conditions, and equipment to be used & if I believe anything is unsafe, will
immediately advise and notify the nearest responsible person of such condition(s) and discontinue further participation in
the Activity. .
2. Acknowledge(s) and fully understand that: (a) each participant will be engaging in activities that involve risks dangers of
damage to personal property and serious injury, including permanent disability, paralysis, and death (“Risks”); (b) these
Risks and dangers may be caused by my own actions or inactions, the actions, inactions, or negligence of others
participating in the activity, the condition in which the Activity takes place, or the negligence of the “releasees” named
below; (c) there may be other risks and social and economic losses either not known to me or not readily foreseeable at
this time; and I fully accept and assume all such risks and all responsibility for losses, costs, and damages I incur as a
result of my participation or that of the minor in the Activity.
3. Hereby release(s), waive, discharge, and covenant not to sue the Mach One SlalomRacingSquad Team, National
Paddling Committee, Inc. dba USA Canoe/Kayak, and American Canoe Association, Inc., its affiliated clubs, their
respective administrators, directors, agents, officers, members, volunteers, coaches, and other employees, or agents of
the organization, other participants, any sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors
of premises on which the activity takes place (each considered one of the “RELEASEES” herein) from any and all claims,
liability, demands, losses, injuries, or damages on account of injury, including death or damage to property, caused or
alleged to be caused in whole or part by the negligence of the releasee or otherwise including negligent rescue
operations; and further agree that if despite this release and waiver of liability, assumption of risk, and indemnity
agreement I, or anyone on my behalf, makes a claim against any of the Releasees, I will indemnify, save, and hold
harmless each of the Releasees from any litigation expenses, attorney fees, loss, liability, damage, or cost which any may
incur as a result of such claim due to my in any way competing, officiating, observing, or working for, or for any other
purpose participating in the event.
I/WE HAVE READ THE ABOVE WAIVER, INDEMNIFICATION, AND RELEASE, UNDERSTAND
THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND I HAVE SIGNED IT
FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT
TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS
HELD TO BE INVALID, THE BALANCE, NOTWITHSTAIDING, SHALL CONTINUE IN FULL FORCE
AND EFFECT. .
Date _______________________
Signatures (minors also require parental):
Printed Names:
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
Address: ______________________________________________________________
City: ____________________________ State ______ Zip ______________
3/1/2010
mach1\forms\applicform.2014