PRA Membership Application Form

Patriot Riders of America MA Ch 7

Member Registration Application
This membership is for those individuals who want to wear a vest to display our back patch. The setup fee includes name tag of MASS Ch 7 and your HANDLER/NICKNAME tag.

Upon completion of six qualifying events, you will be awarded the back patch.

Patched Membership

Setup fee: $66.00 ($50 for back patch and $16 for 2 name tags)
Personal Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Date of birth*

MonthDayYear
Date
Email*
example@example.com
Nickname/ Handle (name on vest)*
Emergency Contact
Name*
Phone Number*

Area CodePhone Number
Contact Relationship:*
I understand that Patriot Riders does not assume responsibility for any aspect of my safety, and that if I participate in any Patriot Riders events, I do so voluntarily on my own assessment of my ability, the routes, and all facilities and conditions, assuming all risks; I release and hold Patriot Riders, its members and officers, harmless for any injury or loss to my person or property which may result. I also hereby certify that I am in compliance with Massachusetts financial responsibility laws regarding the carrying of proper insurance.
Date*

MonthDayYear
Date
Signature*
Should be Empty:

Patriot Riders of America MA Ch 7