Membership Application Form

Annual membership Fee: $25 single, $35 family.

Make checks and application to:

The Piedmont ATV Association
1453 Rolling Hills Road.
Roxboro, NC. 27574 

Please fill one application per rider. 

Name: __________________________________________

Address: ________________________________________

City: _____________________________ State: _________

Phone Number: ______-______-____________

E-Mail Address:  __________________________________

In case of emergency contact:

Name: ___________________________________________

Address:  _________________________________________

Phone: ___________________________________________

Below is some personal info that if you choose to share will be kept within the club and will not disseminated.

Employer:  ________________________________________

Work Hours:  ______________________________________

Date of Birth:  ______________________________________

Piedmont ATV has a members only web site, may we share your personal info disclosed on this form to other club members for riding and club functions?  Yes_____ No _____

Do you support helmet safety?  Yes ______ No  ______

I understand that the Piedmont ATV Association is not responsible for any accidents that occur.  WHEN I RIDE, NO MATTER WHOM THE LAND OWNER IS, I RIDE AT MY OWN RISK.  Neither the landowner nor the club is responsible for any accidents.  If any damages are done to the property that I am riding on, I am responsible for the damage I have made.

I agree to obey the club rules and will ride with safety and personal responsibility.

If you agree to the terms stated above please sign below:

________________________________________________ 

Date: __________________