CAPITAL GOLDEN SKIERS

MEMBERSHIP APPLICATION

FOR AGE 50 YEARS OR OLDER

Member Name: ___________________________Date:______________

Name for Name Tag: Identical, YES____ or OTHER: _____________________

Mailing Address: _____________________________________________

City: ______________________ State: _____ Zip: _________

Phone: Home___________________Work_________________Cell__________________

E-Mail: ____________________________ Fax: __________________

Emergency Contact: Name: _____________________Phone:________________

For couple membership: Spouse/Companion Name ________________________

Phone: Home ______________Work _____________Cell ____________

E-Mail: ________________________Fax: _________________

ANNUAL DUES (From May 1 to April 30)

Individual Membership: $30. Couples: $40. Add $5.00 to receive the Newsletters by US Mail

Make Check Payable To: Capital Golden Skiers

Send Check to: Therese Malambri, Treasurer

Capital Golden Skiers

6407 Birch Leaf Court

Burke, VA 22015

Please check activities of interest:

Ski __ Hike __ Bike __ Music__ Dance __ Theater __ Pot Luck Meals ___

White Water Raft __Kayak __Sailing __ Museums __ Golf __ Trips out of

Area __Beach __ Theme Parks ___Tennis___Bridge___Other______________

Activity Preference: Weekends___ or Weekdays___

How did you hear about us? _______________________________________________________________

To complete your application for membership, please read and sign the Release and Waiver of Liability Form

Rev: 7/21/09

Capital Golden Skiers

Release and Waiver of Liability Form

The Capital Golden Skiers herein referred to as the Club is a year-round social and sports organization providing a variety of activities for its members. These activities include, among others, skiing, hiking, biking, canoeing, kayaking, rafting and dancing, which present inherent dangers that cannot be eliminated even by exercise of reasonable care and are to varying degrees, hazardous. I understand that the Club is a voluntary association run by volunteers who are not professionally trained in conducting sports, cultural, and other activities. By participating, I agree that I am solely responsible for my personal safety and conduct. I agree to indemnify and hold harmless the Club, its officers and board members, trip leaders, and agents or contractors from any loss, cost , or expenses incurred by or attributable in any way to any trip or activity.

I understand that the Club acts only as a coordinator and accepts no responsibility for any person or entity rendering any services or accommodations being offered on any trip. The Club accepts no responsibility in whole or in part for loss and damage of property or injury, including death, to any person; changes in cost; delays; and substitutions in services or accommodations.

The undersigned recognizes that the Commonwealth of Virginia, State of Maryland and District of Columbia have the most significant relationship with the parties to this agreement rather than the destination state, province or country.

This release shall be binding upon the assignees, subrogates, distributes, heirs, next of kin, executors, and administrators of the undersigned and may be pled by the Club as complete bar and defense against any claim, demand, action or cause of action by or on behalf of the undersigned.

I have read and understand this Release and Waiver of Liability Agreement and I hereby apply for membership in the Capital Golden Skiers. I certify that the primary applicant is 50 years of age or older. Note: The spouse or companion need not be 50 years of age or older.

Signature of Primary Applicant: _________________________________

Date: __________________

Print name of Primary Applicant: ___________________________________

Signature of Spouse/Companion: ___________________________________

Date: __________________

Print name of Spouse/Companion: __________________________________