Select one:

New Membership Membership Renewal

Select one:

Individual Membership - $20 Family Membership- $25

First Name:

Last Name:

Address:

Address 2:

City:

State:

Zip Code:

Email Address:

Primary Phone:
xxx-xxx-xxxx

Secondary Phone:
xxx-xxx-xxxx

Gender: (M/F)

Date of Birth:

Year select 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990   Month select 01 02 03 04 05 06 07 08 09 10 11 12  Day select 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

If this is a Family Membership please enter the following information for your spouse.

First Name:

Last Name:

Email Address:

Gender (M/F):

Date of Birth:

Year select 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990   Month select 01 02 03 04 05 06 07 08 09 10 11 12  Day select 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

APPLICATION AND WAIVER:

I know that participating in and volunteering to work in club events are potentially hazardous activities. I should not enter in club activities unless I am medically able and properly trained. I agree to abide by any decision of a race/event official relative to my ability to safely complete the activity. I assume all risks associated with participating in and volunteering to work in club events including, but not limited to, falls, contact with other participants, the effects of the weather, including high heat and humidity, the conditions of the road, water and traffic on the course, all such risks being known and appreciated by me. Having read this waiver and knowing these facts, and in consideration of your acceptance of my application for membership, I, for myself and anyone entitled to act on my behalf, waive and release the CHARLOTTE TRACK & TRIATHLON CLUB and all sponsors, their representatives and successors from all claims or liabilities of any kind arising out of my participation in these club activities even though that liability may arise out of negligence on the part of the persons named in this waiver.