Keystone Multisport Club Membership Form

Member Information Name:

Last First Apartment/Unit # State ZIP Code

Address:
Street Address City

Home Phone: Email Address: Sex: F

Mobile Phone: On Facebook:

) On Twitter: Yes

Shirt Size:

XL

Women Specific Design?

Multisport Information/History Mentor Needed/Desired Available to Mentor USAT Member Multisport History/Highlights: 2013 Races/Goals: Membership/Training Information Membership Type Individual ($50) Payment Method Family ($85) Cash Check Training/Event Interest Triathlon/Duathlon Running (5k/10k) Road Cycling Other Marketing/Sponsor Information How did you hear about us? Facebook Page Retail Flyer/Insert Friend/Member Email Website Adventure Races Running (Half/Marathon) Mountain Biking Trail Running Ultra Running Swimming Specific Events Check No: Early Bird/Discounted ($____) Credit Card Swipe What Disciplines? What Disciplines? USAT No: RRCA Member

What are your favorite products, services, and races? Do you have contacts we could approach about sponsorship?

By indicating your acceptance, you understand, agree, warrant and covenant as follows: Keystone Multisport Club Waiver In consideration of my membership in, and any benefits afforded by, Keystone Multisport Club (KMC), I for myself, executors, heirs, next of kin, administrators, and for anyone else who might claim or sue on my behalf, assume any and all risks and associated with my traveling to or from and participation in a KMC activity, event or workout. I hereby waive, release and discharge any and all claims, losses or liabilities for death, personal injury, partial or permanent disability, property damage, medical or hospital bills, theft or damage of any kind, including without limitation any economic losses, which may arise out of or relate to my participation in or traveling to or from a KMC activity, event or workout that may arise now or in the future against KMC, and its organizers, directors, members, officers, sponsors, volunteers and any other individuals or entities associated with KMC. I also grant permission to KMC and its organizers, directors, members, officers, sponsors, volunteers and any other individual or person associated with KMC to photograph, videotape and record me while participating in a KMC activity, event or workout for the use and publication in promotional materials, advertisement and reports. I further authorize the use and release of my name and photos and age and other directory information. I also grant my permission for a doctor and/or nurse to take remedial action in case of an emergency, and that I assume all expenses in the event of an accident, illness or other incapacity, regardless of whether I have authorized such expenses. By signing below I: (i) agree to and accept the terms and conditions of this Waiver of Liability; (ii) will respect and adhere to all club requirements, benefits, sponsorships, pro-deals, etc.; and (iii) remain a loyal KMC member throughout this enlisted year. Memberships may be revoked at any time with approval of the KMC Board of Directors. KMC MEMBERSHIP AGREEMENT AND LIABILITY WAIVER (the "Agreement and Waiver") 1. Authority to Register and/or to Act as Agent. You represent and warrant to KMC that you have full legal authority to complete this membership registration on behalf of yourself and/or any party you are registering (the "Registered Parties"), including full authority to make use of the check or credit card to which membership dues will be charged. As used in this Agreement and Waiver, KMC refers to Keystone Multisport Club and any and all subsidiaries, affiliated entities, or entities that control or are controlled by KMC singly or together and its officers, directors, members, employees, contractors, subcontractors and agents. If you are registering a child under the age of 18 or an incapacitated adult you represent and warrant that you are the parent or legal guardian of that party and have the legal authority to enter into this agreement on their behalf and by proceeding with this event registration, you agree that the terms of this Agreement and Waiver shall apply equally to all Registered Parties. By registering a child under 18, you agree and consent to the collection of that child's information which you provide for the purposes of registration. 2. Waiver. YOU UNDERSTAND THAT PARTICIPATION IN KMC AND EVENTS ARE POTENTIALLY HAZARDOUS, AND THAT A REGISTERED PARTY SHOULD NOT PARTICIPATE UNLESS THEY ARE MEDICALLY ABLE AND PROPERLY TRAINED. YOU UNDERSTAND THAT EVENTS MAY BE HELD OVER PUBLIC ROADS AND FACILITES OPEN TO THE PUBLIC DURING EVENTS AND UPON WHICH HAZARDS ARE TO BE EXPECTED. PARTICIPATION CARRIES WITH IT CERTAIN INHERENT RISKS THAT CANNOT BE ELIMINATED COMPLETELY RANGING FROM MINOR INJURIES TO CATASTROPHIC INJURIES INCLUDING DEATH. YOU UNDERSTAND AND AGREE THAT IN CONSIDERATION OF BEING PERMITTED TO PARTICIPATE IN ANY KMC EVENT, YOU AND ANY REGISTERED PARTY, THE HEIRS, PERSONAL REPRESENTATIVES OR ASSIGNS OF YOU OR THE REGISTERED PARTY DO HEREBY RELEASE, WAIVE, DISCHARGE AND CONVENANT NOT TO SUE ACTIVE FOR ANY AND ALL LIABILITY FROM ANY AND ALL CLAIMS ARISING FROM PARTICIPATION IN ANY KMC EVENT BY YOU OR ANY REGISTERED PARTY. 3. Indemnification. You agree to indemnify and hold each of KMC harmless from and against any and all damages, costs, claims or demands, including reasonable attorneys' fees, made by any third party due to or arising from or relating to your use of KMC or the violation of any term of this Agreement and Waiver. 4. Applicable Law; Consent to Jurisdiction. KMC and the KMC Internet sites (excluding linked sites) are controlled by KMC from its offices within the Commonwealth of Pennsylvania, United States of America. By completing this membership, both you and KMC agree that the statutes and laws of the Commonwealth of Pennsylvania, without regard to the conflict of laws principles thereof, will apply to all matters relating to KMC, this Agreement and Waiver, the Terms of Use or other use of the KMC Internet sites. You agree that exclusive jurisdiction for any dispute with KMC resides in the courts of the Commonwealth of Pennsylvania and you further agree and expressly consent to the exercise of personal jurisdiction in the courts of the Commonwealth of Pennsylvania in connection with any dispute including any claim involving KMC or its affiliates, subsidiaries, employees, contractors, officers, directors, telecommunication providers and content providers. 5. Severability. You further expressly agree that this Agreement and Waiver is intended to be as broad and inclusive as is permitted by the law of the Commonwealth of Pennsylvania and that if any provision of this Agreement and Waiver shall be found to be unlawful, void, or for any reason unenforceable, then that provision shall be deemed severable from this Agreement and Waiver and shall not affect the validity and enforceability of any remaining provisions. BY INDICATING YOUR ACCEPTANCE OF THIS AGREEEMENT AND WAIVER, YOU ARE AFFIRMING THAT YOU HAVE READ AND UNDERSTAND THIS AGREEMENT AND WAIVER AND FULLY UNDERSTAND ITS TERMS. YOU UNDERSTAND THAT YOU ARE GIVING UP SUBSTANTIAL RIGHTS, INCLUDING THE RIGHT TO SUE. YOU ACKNOWLEDGE THAT YOU ARE SIGNING THE AGREEMENT AND WAIVER FREELY AND VOLUNTARILY, AND INTEND BY YOUR ACCEPTANCE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.

Member Signature:

Date: