MODEL A FORD CLUB OF AMERICA
OLD DOMINION CHAPTER
APPLICATION FOR MEMBERSHIP
Name .Spouse’s Name
Birthday (Mo/Day) Birthday (Mo/Day)
Phone # Cell #
City State ZIP Code
If owned, please list Model A owned by Applicant/Member: (Year and Body Style)
Club Fees: New Member $30.00 Member Renewal $20.00
Total Enclosed $
Make checks payable to Old Dominion Model A Club and remit with completed application and Release and Waiver form to:
Henry Nelson, 3600 New Market Rd., Richmond Va 23231
Is your Model A insured for liability Yes No
If “No” Please give reason
Additional Club Affiliation
Membership is required in one of the following National Clubs:
MARC - Membership #
MAFCA - Membership#
Recommended By Club Member/Mentor:
3/2021 NT NMP
Old Dominion Model A Ford Club (ODMAFC)
Release and Waiver of Liability.
Assumption of Risk and Indemnity Agreement
In consideration of being a member of ODMAFC and participating in any way in any Old Dominion Model A Ford Club events or activities sponsored or otherwise.
I, for myself, my personal representative, heirs and next of kin:
1. Hereby Release, Waive, and Discharge ODMAFC, it Officers, Directors, Members and their heirs, all for the purpose referred to as RELEASEES, from al liability, for any and all loss of damages therefore on account of injury to the person or property or resulting in the death of the undersigned arising out of or relating to as a result of activities associate with Club events, sponsored or otherwise, auto repair assistance, technical advice, and any other area relating to the Model A Hobby.
2. Hereby assume full responsibility and agree to indemnify and save and hold harmless the RELEASEES and each of them from any loss, liability, damage, or cost they may incur due to claims brought against the RELEASEES.
3. Hereby agree that this Release and Waiver of Liability, Assumption of Risk Indemnity Agreement extends to all acts of negligence by the RELEASEES and is intended to be and inclusive as is permitted buy the laws of the Province or State in which activities were held.
4. I grant to ODMAFC the right to take photographs of me and my property in connection the above identified subject in a lawful manor.
I have read this Release and Waiver of Liability, Assumption of Risk and Indemnity Agreement, fully understand its terms, and have signed it freely and voluntarily without any indictment, assurance or guarantee being made, and intend my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.