Chemeketan Membership Application Thunderbird

Instructions: (1) Check the box for either New or Reinstating member. (You are reinstating if you are a member paying after January 31 and are missing your renewal form.) (2) Type in your personal information. (3) Check the box preceding any information you DO NOT want published in the annual Membership Roster. Birth dates are not published. (4) Print this form. Good settings are Portrait, Margins 0.5 inch, No headers or footers, Size 90%. (5) Have the trip leader endorse each qualifying trip. If reinstating, no qualifying activities required. (6) Mail this form along with fee to: Chemeketan Membership Secretary, PO Box 864, Salem OR 97308. You must include leader endorsement from two qualifying trips and the appropriate fee. Fees accompanying applications between October 1 and December 31 will cover the current and following calendar years.

NEW    REINSTATING  (Please provide approximate dates of previous membership & other names you might have used. No qualifying activities required.)

LAST NAME: FIRST NAME:
ADDRESS:
CITY: STATE: ZIP CODE:
BIRTH DATE (mm/dd/yyyy): // (required if under age 18)
PHONE: ()  E-MAIL

Name of Qualifying TripDate of TripEndorsement of Trip Leader
#1:_____________________________________ ___/____/_____ _______________________________
#2:_____________________________________ ___/____/____________________________________

RELEASE FROM LIABILITY AND ASSUMPTION OF RISK
     The Chemeketans is an outdoor recreation club. It consists of people who gather together to enjoy outdoor activities and there is no expectation that the Club is setting itself up as the expert in any of the outdoor activities offered by the Club. It is not a professional outdoor activities guide service. Chemeketans trip leaders are facilitators who volunteer to organize and lead trips. They are not professional guides and are not required to have any specific safety, competency, medical, or other certifications. To help the trip leaders organize the activities they coordinate, the Club has a set of guidelines designed for trip leaders. Trip participants will assume the responsibility for their own safety.
     I am aware that Chemeketan activities including, but not limited to, hiking, backpacking, mountain climbing, skiing, bicycling and canoeing are potentially dangerous, that accidents can happen and that illness can occur in remote places.
     In consideration of being permitted to join and participate in Chemeketan activities, I do for myself, my heirs, legal representatives, and assigns (or, if applicable, as a parent or legal guardian of a minor), assume all risks associated with such activities and traveling to or from such activities, and release and discharge the Chemeketans, their officers and agents from all liability for any and all loss, damage, or claim on account of property damage, death or bodily injury to me, my minor child, or minor child for whom I am legal guardian, caused by the act or failure to act of the Chemeketans, their officers and agents.
     I agree to pay for my own medical and/or rescue expenses, whether or not authorized by me, in the event of accident or illness. I have read and understand this release and sign it voluntarily.

I hereby apply for membership in the CHEMEKETANS. I certify that I have participated in two qualifying trips.

Signature of Applicant _______________________________________ Date ___/___/______

Signature of Parent or Guardian ___________________________________ Date ___/___/______ (required if under age 18)

Fees
Adult Dues (18 and older)$20
Junior Dues (17 or younger)$3
Subscription to paper Bulletin (optional - no charge for e-Bulletin)$20
Fee Total (make your check payable to "Chemeketans")$

Revised 24 July 2017