Membership Form
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Read, print, and sign the form below and send it with your payment to: WOMBATS The WOMBATS Modeling Agency is optional. |
Name
Address
City, State, Zip
Area Code and Phone Number
Email Address
How did you learn about WOMBATS?
Do you want to be contacted by other WOMBATS for rides?
Yes No
Can we put this information on the phone list?
Yes No
Enclosed is my payment for:
| $65 Annual US Membership | |
| $90 for 2 years | |
| $120 for 3 years | |
| $35 for annual renewal (this option is for "re-upping", not for new members) | |
| $65 Non-US Annual Membership |
US membership includes:
- A 100% cotton Wombats Tee Shirt OR Tea Towel
- Quarterly Wombats News issues
- A phone list of members nationwide sent via email
- A cool Wombadge patch
- Wombats car sticker
- Shipping and handling fees
- Quarterly Wombats News issues
- A phone list of members nationwide sent via email
- Shipping and handling fees
Please indicate your tee shirt size and color:
Size: S M L XL
Color: Pink Mint green
I would like the Tea towel instead of the Tee Shirt
Total (please type this in, the form does not add automatically)
Waiver Release of Liability
Please read and sign below:
In consideration of my membership into Women's Mountain Bike & Tea Society (WOMBATS), and of my own free will, I for myself, my heirs, executors and administrators, forever waive, release and give up any and all claims, demands, liability, damages, costs and expenses of any kind whatsoever (including personal injuries to me or my wrongful death) against the WOMBATS and its Officers, Directors, employees, representatives, agents and contractors. I fully realize the dangers of bicycling, which can include, but not be limited to, collision with pedestrians, vehicles, other riders and fixed or moving objects. Dangers can arise from surface hazards, equipment failure, weather conditions or inadequate safety equipment. I assume all risks associated with such participation or while driving to or from bicycling events. I fully understand I am forever giving up, in advance, any right to sue or make any claim against the parties I am releasing if I suffer such injuries and damages, even though I do not know what or how extensive those injuries and damages might be, and am voluntarily assuming the risk of such injuries and damages.
Name
Date
Signature_______________________________________
WOMBATS Modeling Agency (optional)
We are frequently contacted by casting agencies (past accounts: Sunsweet Prunes, Timex, Chevy's restaurants, and more) for active women who ride and are not allergic to cameras, both still and video. As the opportunities have expanded in recent years, we've decided the club would greatly benefit from a donation from successfully completed modeling jobs. In the spirit of mutual support of women and the WOMBATS club, we are asking the future models to hereby agree to share 5% of their paycheck and send that amount to Wombats H.Q.
Yes!! I wanna be a bat model, if the opportunity arises. Check this box and sign this agreement if you want to be contacted by photographers, film and commercial directors, agencies or whatnot.
I want to volunteer my image for a WOMBAT photo on the Web or in a brochure.
I agree to pay WOMBATS at least 5% of all my payment(s) should I luck out and be used in an ad. Moreover I'll do it voluntarily within 30 days of payment.
Name
Date
Signature_______________________________________