Baystate Jeepers, Inc.
c/o Evelyn Howe, Secretary
5 Dalton Avenue
Gloucester, MA 01930

2011 Membership Dues: $50.00

REGULAR MEMBERSHIP APPLICATION, RELEASE FORM,
AND WAIVER OF LIABILITY AND INDEMNITY

It is fully understood by the undersigned that there is some inherent risk associated with participation in Club events, including damage to Jeep® vehicles. In addition, the undersigned agrees to indemnify and hold harmless Baystate Jeepers, Inc., its officers, and participants of any liability. The undersigned agrees to assume full responsibility for his/her actions and those of any minor(s) in their charge which could result in (but not limited to) injury, death, or property damage while participating in a Baystate Jeepers Club event. In addition, all vehicles must meet Baystate Jeepers, Inc. minimum requirements: Tire size 30"+, tow hooks, fire extinguisher, first aid kit, tow strap, CB radio.

Please include a check for your annual dues when submitting this application.

NAME (print)_______________________________________DATE OF BIRTH_____________

STREET ADDRESS_______________________________________________________________

CITY__________________________________STATE________________ZIP_______________

PHONE(H)________________________________(W)__________________________________

OTHER PHONE__________________________________________________________________

E-MAIL_______________________________________________________________________

SIGNATURE_____________________________________________DATE___________________

JEEP® VEHICLE INFORMATION:

MODEL_______________________YEAR_______________________COLOR_________________

TIRE SIZE (30" minimum)_____________________________________

HOW WOULD YOU LIKE TO RECEIVE YOUR NEWSLETTER?        EMAIL      POSTAL

MODIFICATIONS (IF ANY) :
 
 
SPECIAL SKILLS / CERTIFICATIONS USEFUL TO THE CLUB: