Derby City Bop Membership Application Or Renewal

1. Please provide the following contact information: Please Do Not Use All Upper Case or All Lower Case. Proper Punctuation Please

   First Name
   Last Name
   Address One
   Address Two
   City
   State
   Zip Code
   Birth Month & Day	Enter As MM/DD
   Home Phone
   Cell Phone
   E-mail Address

2. Enter the date of this renewal:

   -- mm/dd/yyyy
   

Please Note: By submitting this membership renewal form you are accepting the Release from Liability below.

Release From Liability

THIS RELEASE is executed on the above date at Louisville, Jefferson County, Kentucky, by the above named, herein referred to as "releasor”.    
In consideration of being permitted to participate in any activities conducted by the Derby City Bop Association, releasor for himself, his spouse, legal representatives, heirs and assigns, hereby releases, waives and discharges the Derby City Bop Association, it's officers and members (herein referred to as "releasee"), and each of them from all liability to releasor, releasor's spouse, legal representatives, heirs and assigns, for any and all loss or damage and any claim or damages resulting therefrom, on account of injury to releasor's person or property, even injury resulting in death of the releasor, whether caused by the negligence of releasees or otherwise, while the releasor is for any purpose participating in any activity or function sponsored by the Derby City Bop Association.
Releasor agrees to indemnify the releasees and each of them from any loss, liability, damage or cost they may incur due to the presence of the releasor at any activity or function sponsored by the Derby City Bop Association, whether caused by the negligence of releasees or otherwise.
Releasor hereby assumes full responsibility for the risk of bodily injury, death, or property damage due to the negligence of releasees or otherwise while for any purpose participating in any activity or function sponsored by the Derby City Bop Association. Releasor expressly agrees that this release, waiver and indemnity agreement is intended to be as broad and inclusive as permitted by the laws of the State of Kentucky and that if any portion hereof is held invalid, it is agreed that the balance shall notwithstanding continue in full legal force and effect.
IN WITNESS WHEREOF, releasor has executed this release at Louisville, Kentucky, the day and year of submission via internet transmission.