INDIVIDUAL MEMBERSHIP APPLICATION and WAIVER OF LIABILITY (please print)
INDIVIDUAL MEMBERSHIP APPLICATION and WAIVER OF LIABILITY (please print)
Name (First, MI, Last)_______________________________________________________
Date of Birth__________________________
Address___________________________________________________________________
Suite or Apt # ___________________
City___________________________________ State_______ Zip ____________________
E-Mail Address _____________________________________________________________
Phone_______________________________
Cell _________________________________
# Years at Current Address______________
Concealed Weapon License #________________ State _____ Expiration ____________
Social Security Number (ONLY if you do not have the documents listed below):
__________ - ______ - __________
A $15 application fee must accompany this application. If a background check is necessary, an additional fee of $20 is required.
***If you have a current concealed carry permit, or hold a current membership in another border watch group that required a background check, please send legible copies of your driver's license, concealed carry permit and/or your border watch membership card.
Signature___________________________________________________________________________________________
Date____________________________________________
WAIVER OF LIABILITY
AND ASSUMPTION OF RISK
(Name)__________________________________, hereinafter “Volunteer,” executes this Waiver and Assumption of Risk this _______ day of
____________________ 2008.
In consideration for being able to participate in activities for Patriots Border Alliance, Volunteer, for himself, my legal representatives, heirs and assigns, releases, waives, and discharges Patriots Border Alliance, its officers and members and each of them, their employees and officers, (hereinafter collectively referred to as Patriots Border Alliance), from all liability to Volunteer, Volunteer’s legal representatives, heirs and assigns, for any and all loss or damage, and any claim or damages resulting from the same, on account of injury to Volunteer's person or property, even injury resulting in death of the Volunteer, whether caused by the negligence of Releases or otherwise while the Volunteer is participating in activities for Patriots Border Alliance.
Volunteer assumes full responsibility for the risk of personal injury or death, or property damage whether or not caused by Volunteer's negligence, while in or upon private or public land situated within the State of Arizona, the State of New Mexico, the State of New York, and the State of New Hampshire, and while volunteering, working, or participating in all activities for Patriots Border Alliance.
Volunteer agrees that if any portion of this release and waiver agreement is held invalid under the laws of the States of Arizona, New Mexico, New York and New Hampshire those parts that are not held invalid shall continue in full legal force and effect.
By volunteering for and participating in Patriots Border Alliance, Volunteer recognizes that there are several risks involved. Volunteer understands that these risks may include exposure to harsh elements of nature, such as risk of bodily harm, physical illness or injury from wild animals, exposure to the elements, dehydration, Acts of God, and other risks from nature; Volunteer also understands that these risks include possible injury due to physical activity, ordinary or extraordinary. Volunteer has been made further aware that participation includes the risk of confrontation with illegal aliens, which may result in physical violence or conflict.
By signing this Waiver, Volunteer certifies that he/she has been made aware of the risks involved and Volunteer hereby assumes those risks.
By signing this form, Volunteer hereby agrees and affirms that he/she will not violate any laws, rules, or regulations of the United States or the States of Arizona, New Mexico, New York and New Hampshire or any local ordinances of any county, town, or city in Arizona in which Patriots Border Alliance activities are conducted and in which Volunteer participates.
Volunteer further agree and affirm that he/she will follow all rules and policies of Patriots Border Alliance. Volunteer agrees to adhere to a strict policy of non-confrontation with any suspected illegal aliens and promise to limit my activities to observance of illegal aliens. Volunteer agrees that upon observing any suspected illegal aliens, he/she will promptly report them to the United States Border Patrol and to organizers of Patriots Border Alliance.
Volunteer further agrees and affirms that he/she will conduct himself/herself in a gentlemanly or ladylike and respectful manner at all times, will operate only within the bounds of the law, will defer to all law enforcement officials and follow instructions of law enforcement officials at all times, will respect public and private property and cause no damage, destruction, or depreciation in value to any property, and otherwise conduct himself/herself in a manner that will bring credit to Patriots Border Alliance.
Volunteer understands that should he/she violate any laws, rules, or regulations of the United States or the States of Arizona, New Mexico, New York, and New Hampshire, or any local ordinances of any county, town, or city in Arizona, Arizona, New Mexico, New York, and New Hampshire or rules and policies of Patriots Border Alliance, he/she will be ejected immediately from participation in any further activities and disavowed by Patriots Border Alliance.
__________________________________________ ____________
VOLUNTEER SIGNATURE DATE
Print Name: _________________________________________________
Print Address: _______________________________________________
_______________________________________________
_______________________________________________
Driver’s License # and State: ___________________________________
Mail To:
Patriots Border Alliance
9731 E. Watson Dr.
Tucson, AZ 85730
FAX: 520-885-6553