John Wayne Pioneer Wagon and Riders Association, Inc.
                             Membership Application and Insurance Waiver

P.O. Box 191

Graham, WA 98338

Membership Application and Liability Waiver

 Annual Membership:  (New or Renewing) is from January 1 to December 31 of each year.  New members paying on or after September 1st of their joining year will be paid through December 31st of the following year.  All members may be required to pay other fees for individual JWPWR activities.

Liability Waiver: With my payment for membership and with my signature(s) below, I agree to abide with the John Wayne Pioneer Wagons and Riders Association, Inc. (JWPWR) Bylaws.  I hereby recognize that in accordance with Washington State WAC 4.24.530 and 4.24.540 that any time a participant engages in an equine activity there is a potential for an accident that can cause injuries to horses, riders and spectators and also recognizing the fact the Club, including Officers, or members cannot always know the conditions of the trails or the experience of riders or horses taking part in trail rides or other JWPWR activities and I do hereby release the above named JWPWR, its Officers, its members, and any owners of real property upon which JWPWR activities are held from any claim or right for damages resulting from injury or death that might occur to me, my dependents, or my animals.

I am submitting my annual dues for a: (Choose either Individual or Household membership, not both)

 [  ]  Individual Membership: (one person over age 18)...............Annual Dues:.............$25.00                       
Name printed: _________________________Signature ________________________ Date: _________

Phone____________________Cell____________________E-mail_______________________________

 [  ] Household Membership:...............................................................Annual Dues:......$25.00

    A Household Membership is defined as one or two adults (Primary Members) over the age of 18 living at the SAME address, including any dependents.  The number of Primary Members under this Household Membership is limited to two.  Any dependent listed under this Household Membership must be claimed as a dependent on either of the Primary Member's tax return.  Only the two Primary Members listed under 1.) and 2.) below are eligible to vote. (E-mail addresses will not be included in directories sent to members.)

                             Primary Members:

 1.) Name printed: ______________________Signature:_________________________Date:__________     Phone:____________________Cell:___________________________Email_____________________

  2.) Name printed: ______________________Signature:_________________________Date:__________  Phone:    __________________Cell:___________________________E-mail:____________________

          Dependents:  (Parent or legal guardian must sign for children under 18.)                                   

  1.) Dependent Name:______________________Signature: ___________________ Date:___________

  2.) Dependent Name:______________________Signature:____________________Date:___________

  3.) Dependent Name:______________________Signature:____________________Date:___________

Please list additional Dependents on back of form.   

 Membership Address: ________________________City_________________,State____Zip _______

Emergency Contact:  Name_______________________________Tel. No.________________________

 Phone(s) _______________ Cell  ______________ Fax ___________E-mail_____________________

 [    ]   I am a NEW member    Or      [   ]  I am a RENEWING member

 [    ]   I would like to help with trail or camp activities.

 [    ]   To help JWPWR save expense, please send my Newsletter by e-mail unless this box is checked.