Gold Prospectors of the Rockies PO Box 621988, Littleton, CO 80162-1988 MEMBERSHIP APPLICATION

TYPE:     [   ] New ($40)   [   ] Renew ($30)   [   ] Address Change   [   ] Hold Harmless Signature   Primary member name 1   __________________________________   Birth month _________________   Address    ____________________________________________________________________________   City    __________________________________________    ST    _____    ZIP+4    _________ - _____   Home Phone    ____________________________     Work Phone    _____________________________   E-mail    ______________________________    Home Web    __________________________________   List each additional family member living at the same address. Any family member under the age of 18 must be in the legal guardianship of the primary (1) member, or a claims release must be filed for the child by the legal guardian. Please enclose $10.00 for each badge required for additional family members.   Name 2   _____________________________   Relationship ___________   Birth month _____________  Name 3   _____________________________   Relationship ___________   Birth month _____________  Name 4   _____________________________   Relationship ___________   Birth month _____________  Hold Harmless Agreement For and in consideration of being a member of the Gold Prospectors of the Rockies,
___ ___ I/we do hereby acquit and forever discharge the Gold Prospectors of the Rockies, its owners, members, directors, officers, and any other persons, firms, entities, or corporations of any and all actions, claims, demands, costs, or loss of service growing out of any and all known and unknown personal injuries and property damage resulting from the result of any accidents that could occur on any of the Club owned or leased properties or at any Club sponsored activity on the property of others and not Club owned.
___ ___ I/we the undersigned, do hereby state that I/we have not been influenced to any extent whatsoever in making the release by and representations or statements regarding said injuries, of liability, or of any other matters made by the Club, its owners, members, directors, or officers hereby released or by any person or persons representing or acting for them.
___ ___ I/we understand that members of the Gold Prospectors of the Rockies must abide by all rules and regulations of the Club; USDA Forest Service; BLM; Federal, State, and local laws; and any other government agency's rules and regulations.
___ ___ I/we understand that gold prospecting, like any other outdoor activity, can be dangerous severe injury or death can occur.
___ ___ I/we further state that I/we have carefully read and understand the foregoing release and know the contents thereof and I/we sign the same as my/our free act.
This release contains the entire agreement between the parties hereto, and the terms of the release are binding and contractual.   Primary member signature _________________________________________     Date _______________   Signature 2 _____________________________________________________     Date _______________

Amount paid: $ ______________

FOR CLUB USE:   MTG   USM

Amt Rcvd: ________   Date Rcvd: ________   [  ] Cash?   [  ] Money Order?   Check # __________   Initials: _______   Expiration Mo/Yr: _______     CRD BDG___ NEWS DB LTR    Rev. memberapp0403