Name _____________________________________________ D/O/B __________________
Spouse ___________________________________________ D/O/B __________________
City _____________________________________ ST ______ Zip ___________
Phone (home) ____________________ (work) ____________________
Email Address ________________________________________________________
Emergency Contact - Phone - Relation _______________________________________________________
Do you have a valid drivers license? NO ____ YES ____ Drivers License # ____________________ State _____
Do you carry the required amount of liability insurance for your state? NO ____ YES ____
Year of vehicle ______ Make/Model _____________________________________________
What level of 4 wheel driver are you? Experienced ____ Moderate ____ Beginner____
What do you think you would most enjoy in this club?
By joining the 4 Corners Canyon Climbers of Cortez, I signify that I am aware of the risks and dangers involved. In the case of an accident where I or my vehicle are hurt or damaged in any way, I hereby release the 4 Corners Canyon Climbers for all liability and responsibility.
Signature: _________________________________________ Date: ___________________
BY SIGNING THIS FORM, YOU ARE AGREEING TO THE BYLAWS THAT GOVERN THE 4 CORNERS CANYON CLIMBERS CLUB -- Updated 3/15/03