THIS IS NOT AN ON-LINE SUBMISSION FORM-PLEASE COMPLETE, PRINT THIS FORM AND MAIL BACK TO:

Marlene McGaughey, 44080 Rd 796, Broken Bow, NE 68822

2013 Nebraska 4-D Membership Application

Open 4-D Membership - $30.00 ($35.00 after July 1 of current year)

                  (Eligible to compete in the Open Division. This DOES NOT include newsletter subscription.)

Open 4-D Membership - $35.00 ($40.00 after July 1 of current year)

                  (Eligible to compete in the Open Division.  This INCLUDES newsletter subscription.)

Family 4-D Membership - $20.00 per additional person ($25.00 after July 1 of current year)

                  (Must have one full paying Open Membership, then each additional family member, residing at

                  the same address, qualifies for the rate.  Open Division Eligibility.  No additional newsletter.)

Youth 4-D Membership (13 and under) - $15.00 ($20.00 after July 1 of current year)

                  (Only eligible to compete in the Youth Division.  This DOES NOT include newsletter subscription.)

Youth 4-D Membership (13 and under) - $20.00 ($25.00 after July 1 of current year)

                  (Only eligible to compete in the Youth Division.  This INCLUDES newsletter subscription.)

Nebraska 4-D Release Agreement

By making an application to join the Nebraska 4-D, Applicant agrees to participate at their own risk.  Applicant here by releases and discharges the Nebraska 4-D, it’s Board of Directors, representatives, employees, and agents for all liability, loss, claims, damages and expenses for injuries to person, property, reputation, or financial condition as a result of, or in any way relation to Applicants participation, or failure to participate, in an Nebraska 4-D event, whether caused by negligence, by arena or facility conditions, by the conduct of show management, or the administration of failure to enforce any Nebraska 4-D rule, regulation, bylaw, guideline, or otherwise.  Applicant further agrees that by signing this application, he/she completely releases the Nebraska 4-D from any liability, including negligence.  Applicant voluntarily chooses to participate and abide by all rules and regulations of the Nebraska 4-D.

Signed  _______________________________________________________________ Date _______________

              _______________________________________________________________ Date _______________

               (Parent or Guardian – if applicant is a minor)

 Nebraska 4-D Membership Information

Name   Date

Address 

City State Zip

Phone Work SS#

E-mail

Are you a:  New Member Renewal Member For youth: DOB   Sex: M  F