Application for Membership

Tupelo Tri Club

Name __________________________________      Email _________________________           Gender _________ 

Mailing Address _________________________       Phone ___________________       Fax _________________

City, St Zip ______________________________     Alt Phone ________________        Date of Birth ___________ 

In Case of Emergency Call __________________________ at phone ________________________________

Special Interest (Expertise) area _______________     Occupation (optional) ___________________________

I consider myself : (circle)    Never-done-a-Tri                Beginner                Intermediate          Elite        Ancient

Dues are $20 ($15 for Students) per year.  Please make check out to Tupelo Tri Club and mail to

                Tupelo Tri-Club  // c/o Mark Bresee // 1701 Woodside Circle// Tupelo, MS  38801

Email is the preferred means of communication for this association.   US Mail can be used (delays, cost, etc).  If you desire communication in a form other than Email please indicate which way on this form.

1. I understand and acknowledge that by signing my name below, I am legally agreeing to the statements in the following paragraphs of this agreement (“the Waiver Agreement”) and that these statements are being accepted by the Tupelo Tri Club (“TTC”) in consideration for allowing me to become a member of TTC and/or permitting me to participate in physical training and/or social activities organized by TTC.

2. I acknowledge and agree that it is my sole responsibility to determine whether I am in good enough mental and physical condition to safely participate in physical training, and I attest and certify that I am sufficiently fit and healthy enough to participate in any physical training that I elect to undertake.

3. On behalf of myself and my heirs, estate, assigns, legal guardians, personal representatives and anyone else who might attempt to sue on my behalf, I hereby WAIVE, RELEASE, AND FOREVER DISCHARGE TTC, its officers, directors, agents, members, sponsors, and insurers (collectively, “the Released Parties”) from any and all claims, causes of action, damages, losses (economic and non-economic), and liabilities of every kind for death, personal injury, or property damage that may arise out of, result from, or relate to my participation in any physical training and/or social activity associated with and/or organized by TTC. This waiver, release, and discharge includes but is not limited to any claims for theft, damage to any equipment, negligence, and partial or permanent disability. It also includes but is not limited to claims relating to the provision of first aid, medical care, medical treatment, or medical decisions, and any claims for medical or hospital expenses.

4. I further agree NOT TO SUE any of the Released Parties for any of the claims that I have waived, released, or discharged herein. I AGREE TO INDEMNIFY and HOLD HARMLESS the Released Parties from any and all expenses incurred, claims made, or liabilities assessed against them, including but not limited to attorneys’ fees and litigation expenses and costs, arising out of or resulting from, directly or indirectly, in whole or in part, my breach or failure to abide by any part of this Waiver Agreement and my actions or inactions that cause injury or damage to any other person.

5. I acknowledge and assume all of the risks of running, bicycling, swimming, resistance training, and participation in any other physical training. I also assume any and all other risks associated with physical training, including but not limited to falls, effects of weather (including heat and/or humidity), defective equipment, the condition of roadways, water hazards (including but not limited to swimming in any open body of water), contact with other participants, and any hazard that may be posed by vehicular traffic or pedestrians. I further acknowledge that these risks may be the result of the negligence of the persons released herein.

6. Any person signing below on behalf of a minor under the age of 18 hereby acknowledges that he or she has the legal capacity and authority to act on behalf of the minor and to legally bind the minor to this Waiver Agreement; and he or she agrees to indemnify and hold harmless the Released Parties for any expenses incurred, claims made, or liabilities assessed against them as a result of any insufficiency of legal capacity or authority to act on behalf of the minor in the execution of this Waiver Agreement.

THIS WAIVER AGREEMENT IS A RELEASE OF LIABILITY. DO NOT SIGN THIS WAIVER AGREEMENT IF YOU HAVE NOT READ IT COMPLETELY OR DO NOT UNDERSTAND OR DO NOT AGREE WITH ANY OF ITS TERMS.

________________________________     _____________________________________________

Signature of member or participant                   Signature of parent or guardian if member or participant  is under age 18

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Date