Membership Type _______________________________________
Member Information First Name*
Last Name*
Date of Birth January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
If this is a family membership, please list the name , gender , date of birth and, optionally, email address, for each additional club member. Use the "Additional Names" link as necessary to create a new field for each individual.
Address*
City*
State* Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington District of Columbia West Virginia Wisconsin Wyoming
Zip*
Phone*
Alternate phone
Carolina Godiva Track Club will only use your email address to send you the monthly newsletter and occasional club announcements. You may unsubscribe at any time.
Email*
Email again*
Medical Personnel
As a safety precaution, we like to know who among us might be available to help out if a medical problem happens at one of events, and some of our races require that we have licensed medical personnel on hand.
Please check if you are a(n):
_______________________________
I'm willing to be a medical volunteer at Godiva events
PayPal Email Address
If you plan to submit a PayPal payment, please use the field below to provide the email address associated with your PayPal account, particularly if that address is different from the one provided above, so that we can properly credit the payment to your application.
PayPal Email
Waiver, Release, and Indemnity Agreement
Please read the waiver carefully.
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 agree to abide by any decision of a race official relating to my ability to safely complete the run. I assume all risks associated with running and volunteering to work in club races or events, including, but not limited to, falls, contact with other participants, the effects of the weather, includinghigh heat and/or humidity, 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 anyone entitled to act on my behalf, waive and release the Road Runners Club of America, The Carolina Godiva Track Club, all officers, directors, sponsors, volunteers, their respectives and successors from all claims or liabilities of any kind arising out of my participation in these club activities even though the liability may arise out of negligence or carelessness on the part of the persons named in this waiver. Further, I agree, for myself and anyone entitled to act on my behalf, to hold harmless and indemnify any of the persons or entities mentioned above from all liability, legal, actions, debts, claims, and demands of every nature which arise out of Carolina Godiva Track Club activities. Finally, I grant permission to Carolina Godiva Track Club to use photographs, motion pictures, videos, or any other records of club activities showing my image or likeness, for any legitimate purpose.
You must be over 18 years of age OR the parent/legal guardian of a minor under 18 years of age in order to agree to the terms of the waiver. I consent to the waiver.
By entering my intials in the box below, I electronically sign my acceptance of this waiver.
Signature:*
