| MEMBERSHIP APPLICATION
NAME___________________________________ADDRESS___________________________________________
PHONE#_(___)_______________BIRTHDAY(MONTH)_________EMAIL_________________________________
As a member I hereby certify that I am interested in preserving and promoting Beach Music and the Carolina Shag Dance thru socialactivities and personal contacts. Inconsideration of the mutual benefits derived from membership in the Daytona Beach Shag Club, and acknowledging that an injury may occur while dancing, the applicant does hereby assume all risks and absolves, releases and waives any and all liability claims or demands against the Daytona Beach Shag Club, its Officers, Board of Members and Each and Every Member thereof which may arise out of an act related to an injury.
SIGNATURE APPLICANT/MEMBER__________________________________________________________DATE____________________
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