MAIL FORM WITH CHECK PAYABLE TO
Massapequa Road Runners
P.O. BOX 189
MASSAPEQUA PARK, NEW YORK 11762

  

Membership Application

Please Circle Membership Type

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Membership Page

Family

$20/1 Year

Individual

  $15/1 Year

$30/2 Years

 

  $25/2 Years
M F
Full Name: _______________________________________________
Address: _________________________________________________
Town: ________________________________  City: ________  Zip: __________
Home Phone: _______________ Work Phone: _______________ EMail: ___________________________

Date of Birth: _____/_____/_____

Occupation: __________________________
How did you hear about us _______________________________________________
Family Membership - List additional names and birth dates.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
 
I understand that all MRR activities are intended to promote good health, so I assume responsibility for participating as far as my own physical fitness is concerned, and for any injuries or accidents that might occur as a result. I therefore release and waive any rights or claims for damages which I might otherwise have against the Massapequa Road Runners, Inc., as well as other persons or party connected with the Club's activities, their officers, administrators, successors, or assigns.
 
Date: ______________   Signature: _____________________________________
Application must be signed by a parent or guardian for members under the age of 18

MASSAPEQUA ROAD RUNNERS, INC.
P.O. BOX 189
MASSAPEQUA PARK, NEW YORK 11762