Membership Application/Renewal

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Name:*

Email:*

Address Line 1:*

Address 2:

City:*

State:*

Zip:*

Home Phone:

Cell Phone:*

AMA #:

Dist 37 Number - DESERT:

Dist 37 Number - GP:

Dist 37 Number - ENDURO:

Racing Division and Skill Level:

Bike Make/CC:

Sponsors (separate with comma):

EMERGENCY CONTACT INFO

In emergency notify:*

Relationship:*

Phone:*

Alt Phone:

#2 Relationship:

#2 Phone:

#2 Alt Phone:

I apply for, or renew membership in the 100's M.C., Inc., and agree to abide by its rules and by-laws. I understand that the 100's M.C. Inc., its Officers, The American Mortorcycle Association (AMA), and District 37 cannot assume responsibility for any aspect of my safety. I also understand that if I participate in any 100's M.C. club event, or any AMA sanctioned meet, I do so voluntarily on my own assessment of my ability, the track, course, and all facilities and conditions, assuming all risk. I release and hold harmless the 100's M.C., Inc., its officers, its members, the AMA and District 37 for any injury or loss to my person or property, which may result from my participation in sanctioned events. I have read and understand this release.

By checking this box I have read and agree to the above disclaimer:*

Once you submit this form, you will be taken directly to PayPal to pay your $20 membership dues.