Durham Divas, Women Born To Ride

Application Form

Please note, most fields are required.

Membership Fee is $30.00

Membership Type:

New
Renewal

Application Type:

Rider
Non Rider

Name:*

Address:

Street:*

City:*

Postal Code:*

Email:*

DOB MM/DD/YY:*

Enter a 0 for phone number fields if you have no home/cell phone.

Home Phone:*

Cell Phone:*

How long have you been riding your own motorcycle? indicate N/A for Non-Rider

Riding*

Make and Model of your Ride

Note: If your Motorcycle Model is not here, let us know here so it can be added. Enter it on the 3rd field.

Motorcycle Make: *

Motorcycle Model:*

Model:

Current Mileage:*

License Type

None M1 M2 M

Have you ever done Group Riding?

Group?

Yes No

Are you a member of another motorcycle organization?

List them below

Other Clubs

Photo Publications

Do you agree to have first name and last initial and photo published for the public site?

Public Site?

Yes
No

How did you hear about us?

Hear?*

In Case of Emergency

The following information will be held in the strictest of confidence and will be used only through the result of an EXTREME EMERGENCY. (If related give other than home phone #)

Emergency Contact:*

Emergency Relationship:*

Emergency Phone # *

By submitting this form your Application is considered as signed.

Please enter the phrase as it is shown in the box above.

I / We understand and agree that this application is subject to the policies, rules, and regulations of Durham Divas Club, in force at this time or at any time in the future. I / We hereby agree to and will pay membership dues in the amount determined by the executive committee of Durham Divas.

RELEASE OF ALL LIABILITY AND INDEMIFICATION AGREEMENT:

In consideration of the privilege of submitting this application, I / We do hereby for myself / ourselves and for my / our children under the age of twenty (20), my / our heirs, executors, administrators, and successors, assign, release and forever discharge the Durham Divas Club, its officers, directors, and agents from any and all losses, claims, demands, actions, suits at law and in equity, judgments and executions which I / We had, now have, or may in the future have, arising from or by reasons or any and all bodily or personal injuries whether known or unknown, death, and / or property damage resulting from, in connection with or rising out of social events, social gatherings, social functions, motorcycle and / or other trips, travel to and from and / or other activities, and any other motorcycle activities, and any and all other motorcycle activities, and any other activities of any kind or description in any way connected with the Durham Divas Club.

I / We acknowledge that the sport of motorcycling is a dangerous activity that can result in personal or bodily injury, included but not limited to or loss of personal property, including but not limited to, motorcycle equipment. Furthermore, in consideration for the privilege in submitting this application, I / We on behalf of all family members under the age of twenty (20) listed above, and on behalf of my / our and their heirs, executors, administrators, or assigns, hereby agree to and will indemnify the Durham Divas Club, its officers, directors, and its agents and hold them harmless from any suits, filing fees, costs of collection, and attorney fees.

I / We have read the foregoing APPLICATION AND RELEASE OF LIABILITY AND INDEMNIFICATION AGREEMENT and understand all of the terms thereof. I / We execute it voluntarily and with full knowledge of its significance.

Personal information collected on this application is for the Durham Divas to use for the purpose of managing the membership database, conducting club business and for motorcycle related purposes. Members’ contact information will be made available to other members for the same purposes.