NAME ______________________________________________ BIRTHDATE _______________
ADDRESS ____________________________________________________________________
CITY ___________________________________ STATE _____ ZIPCODE _________________
HOME PHONE _________________________ WORK PHONE __________________________
E-MAIL _______________________________________________________________________
Other Family Names (if family membership)___________________________________________
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TYPE OF ANNUAL MEMBERSHIP
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ARE YOU CURRENTLY A MEMBER OF IMBA?
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Please read and sign the following waiver:
In consideration of my membership in the Southern Oregon Mountain Bike Association (SOMBA), I hereby waive, release, and discharge any and all claims for damages, death, personal injury, or property damage which I may have, or which may hereafter accrue to me, as a result of my participation in the organization. This release is intended to discharge in advance the Southern Oregon Mountain Bike Association (SOMBA) organization or officers, the International Mountain Bicycling Association (IMBA), and any involved municipalities or other public agencies, from and against any and all liabilities arising out of or connected in any way with my participation in the organization. By signing this release, I hereby agree to the terms of this release.
Signature _______________________________________________ Date __________________
Signature of Parent/Guardian _______________________________ Date ________________
(if participant is under 18)
* Mail to SOMBA, PO Box 1196, Talent, OR 97540. For additional information e-mail info@somba.org.