Lake County MilersRenewal and New Membership Application for calendar year—2009/2010
New Membership application ___Renewal ___Name and/or address change___
Dues: (Check the one that applies)
____Student Membership (Junior High thru College) $5.00 annually
____Individual membership--$10 annually
____Family membership (2 or more) $15.00 annually
Mail application and check to:
Lake County Milers, PO box 490, Middletown, Ca. 95461 or bring to Club Run
Info: 707-987-3229 or email jmburnett2@mchsi.com
Note-your email address allows us to keep you informed!
Name:____________________________________email:________________________
address:________________________________City:________________Zip:________
Contact Phone: ___________________________Sex: ____ Birth date: ____________
Name:____________________________________email:________________________
Contact Phone: ___________________________Sex: ____ Birth date: ____________
Name:____________________________________email:________________________
Contact Phone: ___________________________Sex: ____ Birth date: ____________
Name:____________________________________email:________________________
Contact Phone: ___________________________Sex: ____ Birth date: ____________
Club Membership Application waiver:
I know that running and volunteering to work in club races are potentially hazardous activities. I should not enter and run in club activities
unless I am medically able and properly trained. I assume all risks associated with running and volunteering in club activities including, but
not limited to, falls, contact with other participants, the effects of the weather, the conditions of the road and traffic on the course, all such
risks being known and appreciated by me. Having read this waiver and knowing these facts, and in consideration of your acceptance of my
application for membership, I, for myself and my dependents, or anyone entitled to act on my behalf, waive and release the Lake County
Milers Club members, officers, Hidden Valley Lake association, the County of Lake, and all sponsors, their representatives and
successors from all claims or liabilities of any kind arising out of my participation, or that of my dependents in any club activity, even though
that liability may arise out of negligence or carelessness on the part of the persons or groups named in this waiver.
Signature:_____________________________ Date:_____________________
If under 18 must be signed by parent or guardian
New Membership application ___Renewal ___Name and/or address change___
Dues: (Check the one that applies)
____Student Membership (Junior High thru College) $5.00 annually
____Individual membership--$10 annually
____Family membership (2 or more) $15.00 annually
Mail application and check to:
Lake County Milers, PO box 490, Middletown, Ca. 95461 or bring to Club Run
Info: 707-987-3229 or email jmburnett2@mchsi.com
Note-your email address allows us to keep you informed!
Name:____________________________________email:________________________
address:________________________________City:________________Zip:________
Contact Phone: ___________________________Sex: ____ Birth date: ____________
Name:____________________________________email:________________________
Contact Phone: ___________________________Sex: ____ Birth date: ____________
Name:____________________________________email:________________________
Contact Phone: ___________________________Sex: ____ Birth date: ____________
Name:____________________________________email:________________________
Contact Phone: ___________________________Sex: ____ Birth date: ____________
Club Membership Application waiver:
I know that running and volunteering to work in club races are potentially hazardous activities. I should not enter and run in club activities
unless I am medically able and properly trained. I assume all risks associated with running and volunteering in club activities including, but
not limited to, falls, contact with other participants, the effects of the weather, the conditions of the road and traffic on the course, all such
risks being known and appreciated by me. Having read this waiver and knowing these facts, and in consideration of your acceptance of my
application for membership, I, for myself and my dependents, or anyone entitled to act on my behalf, waive and release the Lake County
Milers Club members, officers, Hidden Valley Lake association, the County of Lake, and all sponsors, their representatives and
successors from all claims or liabilities of any kind arising out of my participation, or that of my dependents in any club activity, even though
that liability may arise out of negligence or carelessness on the part of the persons or groups named in this waiver.
Signature:_____________________________ Date:_____________________
If under 18 must be signed by parent or guardian
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Interested in joining the Lake County Milers? You don't have to be a resident of Lake County to join - We
accept runners from all over the County, State and Country! Simply print this form, complete the entries, and
mail it along with your payment to the address shown. It's just that simple.
accept runners from all over the County, State and Country! Simply print this form, complete the entries, and
mail it along with your payment to the address shown. It's just that simple.
NEW! Pay your dues online by clicking here.
Note: A small service charge applies.
Note: A small service charge applies.
