MODEL A FORD CLUB OF AMERICA
OLD DOMINION CHAPTER
APPLICATION FOR MEMBERSHIP 


Name ___________________________     Telephone______________________________

Other____________________________    Telephone ______________________________

Address ___________________________________________________________________

Occupation _________________________________________________________________

Model A Body Style ___________________________________________________________

Email _______________________________________________________________________

		Initiation Fee		$10.00     ________________
		Dues			$20.00     ________________

				Total Enclosed     ________________

Make checks payable to MAFCA Old Dominion Chapter and remit, with completed application to:  Dennis Stone, Old Dominion Chapter, 300 Stillbrook Ct, N. Chesterfield, Va. 23236

Is your Model A insured for liability?		Yes ______	No  ______

If “No” please give reason ________________________________________________________
(This is a requirement of this club for your benefit)

Additional affiliation: MARC #_________________ MAFCA #____________________


						Signature _________________________________
Recommended by:

________________

________________

												11-30-22

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, its Officers, Directors, Members and their heirs, all for the purpose referred to as RELEASEES, from all 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 associated 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 in 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. 
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Signature Date 
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Signature Date