Date
MM
DD
YYYY
Name
*
First Name
Last Name
Name as you want it to appear in our directory.
*
Complete Street Address/Unit #
*
City
*
Zip Code
*
Home Phone
(###)
###
####
Cell Phone
(###)
###
####
Name of Subdivision or Condo
*
Email
Birthdate
MM
DD
YYYY
I moved to Brevard County and made this my permanent home
*
(Provide Mo./Year, enter "01" for date)
MM
DD
YYYY
If I vote, I will be voting in Brevard County at the next election
To get to know you better, other than Florida, what do you consider your home state?
Who, if anyone, invited you to join?
Please check any of the activities below in which you may be experienced and/or interested:
Other games or interest areas:
Other experiences that may be of service to the club
1. I, the applicant below, wish to take part in the activities and/or programs organized by CENTRAL BREVARD NEWCOMERS’ CLUB and hereafter known as CBNC.
*
2. I hereby agree that the participation in the activities and/or programs of CBNC is voluntary and at my own risk. As a condition of my participation in the activities and/or programs, I agree to discharge, waive and release CBNC, its officers and members from any and all suits, claims, demands, injuries, illness and/or liabilities.
*
3. CBNC does not assume any responsibility for any injury, illness, harm, loss or consequences participants and members may sustain while taking part in CBNC activities. CBNC merely organizes such activities by putting out schedules and meeting places. All participation by members is completely voluntary. These activities include, but are not limited to, members who host events in their residence and members who provide transportation (i.e. carpools) for other members. This Waiver and Release shall remain in effect and be binding during the period of your membership and any and all renewals thereof.
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By entering my name below, I state that the information is true and correct, and I will abide by the Bylaws of the Central Brevard Newcomers’ Club. I also state that I have read and understand and acknowledge my knowing and voluntary consent to the terms of the General Waiver and Release by signing this Agreement. I agree that this General Waiver and Release full and accurately expresses my understanding and has not been modified orally or in writing.
*
Submission Date
MM
DD
YYYY
