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2007 MX MEMBERSHIP APPLICATION
PLEASE SEND TO:
DANA BARLOW
4860 SOUTH 2200 WEST, TAYLORSVILLE, UTAH 84118
$25.00
Registration - MOTOCROSS ONLY
NAME________________________________________________PHONE ( )_________________
ADDRESS_____________________________________________________________APT#________
CITY__________________________________________STATE________________ZIP___________
RELEASE AND
WAIVER OF LIABILITY AND INDEMNITY
I, THE UNDERSIGNED, FOR MYSELF AND FOR MY HEIRS,
PERSONAL REPRESENTATIVES AND ASSIGNS, DO HEREBY RELEASE AND FOREVER DISCHARGE
THE UTAH SPORTSMAN RIDERS ASSOCIATION INC. AND ANY OTHER PERSON, FIRM OR
CORPORATION CHARGED OR CHARGEABLE WITH RESPONSIBLITY OR LIABILITY, THEIR HEIRS,
REPRESENTATIVES AND ACTIONS AND CAUSE OF ACTION, ARISING FROM ANY ACT OR
OCCURANCE, AND PARTICULARLY ON ACCOUNT OF PERSONAL INJURY DISABILITY, PROPERTY
DAMAGE, LOSS DAMAGE OF ANY KIND THAT I MAY HEREAFTER SUSTAIN AS A RESULT OF
PARTICIPATING IN AN EVENT NAMED AS USRA SANCTIONED.
I FULLY UNDERSTAND THE NATURE OF THE ACTIVITIES TO BE
CONDUCTED BY UTAH SPORTSMAN RIDERS ASSOC. INC., ACKNOWLEDGE THE HAZARDS OF SAID
ACTIVITIES AND VOLUNTARILY ASSUME THE RISK OF INJURY TO MY PERSON, PROPERTY, OR
PROPERTY OF OTHERS.
NOTE: YOUR MEMBERSHIP DOES NOT IN ANYWAY INCLUDE OR GUARANTEE TO ANY
INSURANCE COVERAGE OF ANY KIND. INSURANCE, IF ANY, PROVIDED BY A USRA
SANCTIONED CLUB, IS WITHOUT COST TO YOU AND MAY INCREASED, DECREASED, CANCELED
OR CHANGED IN ANYWAY BY THE SANCTIONED USRA CLUB AT ANY TIME AT ITS SOLE
DISCRETION.
IF MEMBER IS UNDER THE AGE OF 18 YEARS, THIS FORM MUST
BE SIGNED BY HIS OR HER PARENT OR LEGAL GUARDIAN.
THE USRA RESERVES THE RIGHT TO REFUSE OR
REVOKE MEMBERSHIP TO ANYONE.
CAUTION: READ RELEASE & WAIVER BEFORE SIGNING
MEMBER
SIGNATURE___________________________________________________________________
PARENT / GUARDIAN
SIGNATURE________________________________________________________
AGE on JAN 1,
2007____________________________ BIRTHDATE_______________________________
BIKE
BRAND_______________BIKE MODEL____________ BIKE SIZE_________2 or 4 STROKE_____
USRA CLASSES FOR MOTOCROSS
ABILITY (Choose One):
PRO ____ INTERMEDIATE
____ JUNIOR ____ BEGINNER (First Year Racers Only) ____
CLASS (Choose
all that apply):
125 (125 2-Stroke/250-4 stroke)____ 250 (250
2-Stroke/450-4 Stroke)____ Open____
Over-25____ Over-30____ Over-40 (Heads-Up)____
ATV____ Women____ Sportsman____
Pee Wee
Shaft Drive____ Pee Wee Stock
4-6____ Pee Wee Stock 7-8____ Pee Wee Open____
Powder
Puff____ Pee Wee Pit Bike____ 65cc 6-8____ 65cc 9-11____ 65cc
Open____
Mini Women
____ 85cc Beg____ 85cc 7-11 Jr____ 85cc 12-15 Jr____
Supermini____