PINOY HARLEY RIDERS CLUB (PHRC)
Membership Form and Waiver/Release
Agreement
Member Name: ____________________________________ Member No. _______________
Address:
_______________________________________
City: ________________________________ State: ____________ Zip: ______________
Telephone Number: _____________________
E-mail: ____________________
Date of Birth: _________________
Motorcycle Model / Year:
______________________
Insurance Co. _______________________ Policy No. _______________
In Case of Emergency:
Contact name:___________________________________
Phone:_______________________
WAIVER
OF RIGHTS
I hereby consent and agree to waive all rights and benefits arising out of any State Statute that would
limit and/or negate the coverage and scope of this release and Indemnification Agreement including, but not limited to, the
provisions of Section 1542 of the California Code.
RELEASE OF LIABILITY
I agree that the sponsoring Club,
Pinoy Harley Riders Club (PHRC), and its officers, members, representatives, and agents shall not be liable or responsible
for damage to property or any injury to persons including myself during any event or activity even when the damage or injury
is caused by neglect. I fully understand and hereby agree that all PHRC members and their guests voluntarily participate at
their own risk in all PHRC activities / events, and likewise assume all risks of injury and damages that may arise thereof
during such activities / events. I understand that this means I agree not to take any legal action against PHRC or any of
its members for any damage to property or injury to persons including myself as a result of or in connection with any PHRC
activities or events.
Member Signature: ________________________ Witness: __________________________
(PHRC Officer)
Date: _______________________
Membership Dues : $ ___________ $ Rcvd. __________
Balance due $ ___________
