Eugene Petanque International Club (EPIC)
Membership Form
Membership Our club is affiliated with the Federation Petanque of the United States of America (FPUSA). When you join our club, you receive a card from the FPUSA that allows you to participate in FPUSA activates and tournaments throughout the country. FPUSA affiliation also provides the club with liability insurance.
Dues are $25 a year. (Fifteen dollars of this fee goes to the FPUSA and $10 goes to our club to help support our activities.)
To Join: 1. Fill out the following information: Name ________________________________________________________
Address ______________________________________________________
Telephone ____________________________________________________
Citizenship ___________________________________________________
Date of Birth _________________________________________________
2. Sign the waiver on the back.
3. Attach a check payable to Eugene Petanque International Club for $25 and send to:
Lou Favreau
31338 Fox Hollow Rd
Eugene, 97402
4. We also need a JPEG photo (portrait) for your ID. You may email one to ray6448@gmail.com or we can take one for you at University Park.
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Waiver Form
REQUIRED FOR ALL ADULT MEMBERS AND PARTICIPANTS IN FPUSA CLUB ACTIVITIES
ACCIDENT WAIVER AND RELEASE OF LIABILITY
Insured: Member Clubs & Events of
Federation of Petanque USA
Sport Activity: Pétanque
I acknowledge that this sport is an extreme test of a person’s physical and mental limits and carries with it the potential for death, serious injury and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of athletes, equipment vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, event officials, and event monitors, and/or producers of the event and lack of hydration. These risks are not only inherent in athletics, but are also present for volunteers.
I hereby assume all of the risks of participating and or volunteering in this sport’s events.
I realize that liability may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them or because of their possible liability without fault.
I certify that I am physically fit, have sufficiently trained for participation in the event and have not been advised otherwise by a qualified person.
I acknowledge that this Accident Waiver and Release of Liability form will be used by the event holders, sponsors and organizers, in which I may participate and that it will govern my actions and responsibilities at said events.
In consideration of my application and permitting me to participate in this sport, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: To waive, release and discharge from any and all liability for my death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter accrue to me including my traveling to and from events, the following entities or persons: Federation of Petanque USA, its Member Clubs, and Sanctioned Events
I hereby consent to receive medical treatment which may be deemed advisable in event of injury, accident and or illness during this event.
I understand that at this event or related activities, I may be photographed. I agree to allow my photo, video or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers and assigns.
The Accident Waiver and Release of Liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
I hereby certify that I have read this document and understand its content.
PARTICIPANT’S NAME
SIGNATURE OF PARTICIPANT DATE SIGNED
PLEASE PRINT IN CAPITALS (MM/DD/YY)
FPUSA MEMBER CLUB:
PARTICIPANT ACCIDENT WAIVER & RELEASE OF LIABILITY
( Signed original to be sent to the FPUSA Secretary, PO Box 180, Kenwood, CA 95452.)
