Address________________________________________________________________

City, State and Zip code___________________________________________________

Phone#___________________________ Cell#_________________________________

Email__________________________________________________________________

Emergency Contact Name____________________________ Phone#_____________

Vehicle #1_______________________________________________________________

Vehicle #2_______________________________________________________________

Other Clubs/Organizations________________________________________________

Special Skills____________________________________________________________

________________________________________________________________________

I agree to pay the current annual dues of $50.00 to the Club as spelled out in the Club bylaws, and that I have read these bylaws and will adhere to them for the benefit of myself and the Club.

Print Name___________________________Signed___________________Date______

Release and Indemnification Agreement

I, the undersigned, fully understand that Western Mass. 4x4 (herein referred to as the Club) is an organization that participates in and sponsors events and activities that can be inherently dangerous. I acknowledge the risk of damage to my vehicle, injury or death to my guests, others, or myself. I agree to hold harmless the Club, it’s members, officers, directors, trail leaders, spotters, delegates, private property owners, sponsors, and supporters while participating in these events and activities. Furthermore I waive and release any and all rights and claims for damages for myself, my heirs, executors and administrators I have or may have against the Club. I will accept full responsibility and liability for any damages or injury to my vehicle, my guests, others, or myself or property, which may result from any accident which occurs during Club events or activities.

Print Name___________________________Signed___________________Date_____