les bon temps Road Racing Club

Membership Form

RUNNER

WALKER

W/Chair

Annual Individual Membership $25

Senior (Over 60) $15

CYCLER

Annual Family Membership $30

Youth (17-Under) $15

FAMILY MEMBERS

NAME

LAST

FIRST

INITIAL

MEMBERSHIP #

NAME (Last, First, MI)

DOB

Sex

ADDRESS

MEMBERSHIP #

NAME (Last, First, MI)

DOB

Sex

CITY

STATE

ZIP

MEMBERSHIP #

NAME (Last, First, MI)

DOB

Sex

TOTAL

DOB

SEX

PHONE/HOME

OFFICE

OFFICIAL USE ONLY: MEMBERSHIP #

EXP. DATE

ENCLOSED

I know that running and volunteering to work in club races are potentially hazardous activities. I should not enter and run in club activities unless I am medically

able and properly trained. I agree to abide by and decision of a race official relative to my ability to safely complete the run. I assume risks associated with running

and volunteering to work in club races including, not limited to, falls, contact with other participants, the effects of the weather, including high head and/or humidity,

the act on my behalf, waive and release the les bon temps Road Racing Club and all sponsors, their representatives and successors from all claims of any

kind arising out of my participation in these club activities even though that liability arise of negligence or carelessness on the part of the persons named in this waiver.

SIGNATURE

DATE

SIGNATURE

DATE

(signature of parent or gaurdian if applicant is under 18)

I grant permission to all of the foregoing to use any photographs, motion pictures or any other record of the event for any legitimate purpose.

I understand that skateboards, baby joggers, roller skates or blades, animals, and radio headsets are not allowed in the race and I will abide by this quideline.

MAIL TO:

les bon temps Road Racing Club

Lutcher, LA 70071

Attention: Dale Hymel