Havasu Gold Seekers, Inc
Individual or Family Membership Application & Hold Harmless Agreement
This is an example of the Membership form, please click on link to the left to print off application.
Last Name___________________First Name________________ Spouse or Partner_____________________
Name (s) of Minor Children_______________ Age____ _______________Age___ _____________________
Age____ __________________ Age____ _______________ Age____ ________________________________
City___________________________ State ___________________________ Zip________________________
Day Phone ________________________________Evening Phone____________________________________
Mail Address (same )________________________________________________________________________
City___________________ State ____________Zip________ E mail address___________________________
Yearly Individual or Family membership dues are $ 40.00 for Jan 1st thru Dec 31
Initiation Fee for Individual or Family membership is $ 100.00. Total cost for new membership is $140.00
$ 40.00 for each subsequent year which is Jan 1 Thru Dec 31
Prospecting Vehicle Make:_______________Year______Color_________ Lic._________________State_____
Prospecting Vehicle Make: _______________Year_____ Color_________Lic._________________ State_____
Metal Detector Make:___________________________Model _______________________________________
Other Equipment:____________________________Member of any other Prospecting Clubs:_______________
I / We, the undersigned,( herein after referred to as participant ) assume all risks and or hazards association with participant’s involvement in the Havasu Gold Seekers, Inc. Prospecting Association. Participant agrees to indemnify and hold harmless all Club Officers, Sponsors and/or other, fourth, fifth, etc. parties involved in club activities.
Participant realizes that metal detecting, gold prospecting and associated activities can be dangerous. The terrain can be hazardous and may be wild and domestic animals, insects, snakes, etc. present. Some locations may have open shafts, pits and tunnels. Some areas may be suitable only for four –wheel—drive vehicles.
Participant assumes full responsibility for any injury, loss or liability which may result or be alleged to have resulted from involvement in these activities. This includes, but is not limited to, loss of life, limb and sight. Loss and liability is also accepted for, but limited to metal detector, mining equipment, pets and vehicle. This agreement includes the trip to and from the actual location of Havasu Gold Seekers, Inc. properties and claims.
In case of injury or sudden illness, Participant hereby accepts needed first aid and gives authorization to any hospital, doctor or emergency personnel to render immediate emergency aid as may be required at the time for Participant’s health and safety.
It is understood by Participant that the expense of professional services is accept by Participant. This document applies to any and all activities while on Havasu Gold Seekers, Inc. properties or claims in which Participant is
involved. It applies not only to the date of signature but to any and all future dates. This will be in effect until and unless revocation is received.
Bring this application to the next Club meeting or mail application and your check to;
Havasu Gold Seekers Inc., P.O. Box 3281 Lake Havasu City, AZ. 86405-3281
Signature of participant:__________________________________________________________Date___________
Signature of Participant:_________________________________________________________Date ___________
Name (s) of Minor Children:_____________________________________________________________________
Signature of Parent (s) or Legal Guardian (s)