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First Name: ________________ Middle Initial: ___ Last Name _______________________
Address: __________________________________________ Apt. #__________
City _____________________ State ________ Zip ____________ Birthday ______/____
MM/DD
Phone: (Home) _______________ (Work) ______________ Email ___________________
The purpose of Mosaic is to provide the Jewish Community with outdoor group experiences, to foster Jewish awareness of nature and the natural environment and to provide a positive setting for the exchange of outdoor knowledge and experiences within the Jewish Community, and to educate and create in its members, an awareness, interest, and understanding of the importance of appreciating and preserving our natural environment, and Jewish heritage. All persons 21 years of age or older are eligible to join the club.
Membership Type: Individual ($20 per year), Family Membership: ($30 per year) Please make check payable to Mosaic Outdoor Mountain Club of Central Florida ("Mosaic"), and mail to the above address. Check here if you do not want your name and telephone number included in our directory & distributed to members. ______
Check here if you might be interested in serving on a committee or the Board. _______ .
Area (s) of interest? _______________________
Membership is not effective until this application, completely filled out and signed with payment enclosed, is received by the Membership Director. As a member, you are also entitled to vote in all general membership meetings, and to participate in all Mosaic activities without having to pay a non-member surcharge.
The undersigned agree(s) to uphold and comply with the purpose, policies and by-laws of Mosaic. I/We represent that I/We am at least 21 years old and I/We have read and agree to the terms and conditions of the following RELEASE OF LIABILITY.
RELEASE OF LIABILITY
By signing below, I/We acknowledge that all activities sponsored or conducted by the Mosaic may be hazardous, and may result in personal injury, loss, damage, or death. With full knowledge of these dangers, I/We hereby agree for myself, and all of my family and heirs, to RELEASE Mosaic and any of its chapters, groups, representatives, volunteers, officers, directors, members, or agents, from any and all liability, claims, or any causes of action, and NOT TO SUE OR OTHERWISE MAKE ANY CLAIM against Mosaic, or any of its chapters, groups, representatives, officers, directors, members, or agents which may arise during my participation in any Mosaic activities.
I/We intend this RELEASE OF LIABILITY to be effective whether or not any loss, damage, injury, or death RESULTS FROM NEGLIGENCE of Mosaic or any of its agents, leaders, instructors, volunteers, guides, officers, directors, members, or representatives. I/We understand that negligence means a failure to act in a reasonably prudent manner under the same or similar circumstances, in order to protect oneself or others from injury, loss, or death.
I/We agree to be solely responsible for my own safety and to take every precaution to provide for my own safety and well-being while participating in activities of Mosaic.
I/WE HAVE READ AND AGREE TO THE ABOVE.
Signature________________________________________Date___________________
Signature__________________________________________________Date___________________
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