Derby City Bop Membership Form

Derby City Bop Membership Form

Use this form for new membership applications or for membership renewal
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Home Phone
E-mail*
Birthday

MonthDayYear
DCBA Membership*
prevnext( X )
DCBA Membership$41.00
Please Note: By Submitting This Membership Application You Are Accepting The Release From Liability Agreement Shown Below.
THIS RELEASE is executed 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 Derby City Boogie Dancers Inc, herafter known as Derby City Bop, releasor for himself, his spouse, legal representatives, heirs and assigns, hereby releases, waives and discharges the Derby City Bop, 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.

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, 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. 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.
Click To Sign*

I Agree To This Release From Liability
Enter the message as it's shown*
Should be Empty: