2012 Membership Application

 Western Pennsylvania Mushroom Club

The purpose of the Western Pennsylvania Mushroom Club is to promote the enjoyment, study, and exchange of information about wild mushrooms. Anyone who has an interest in wild mushrooms is welcome to become a WPMC member.

Members are entitled to:

• The WPMC newsletter
• Nine monthly WPMC meetings
• Free participation in WPMC walks
• Fee discount for WPMC forays

Name:  ____________________________________________                      Date_________

Address: ___________________________________________

City: ____________________________ State:_____________ Zip: __________

Phone: _________________________________

E-mail:_________________________________

(please print clearly or attach address label)

Annual dues: - $15 Individual -- $20 Family -- $10 Full Time Student

Dues enclosed: $____________

Please return completed, signed and dated form (with check payable to Western PA Mushroom Club) and Release Form signed in 2012 will be in effect until termination of membership. (Please return with payment) to:

WPMC, c/o Jim Wasik, 70 Woodland Farms Road, Pittsburgh, PA 15238

                                    e-mail contact: WPMC.membership@gmail.com

or visit www.wpamushroomclub.org to pay using credit card.

Normal Meeting Location

Please indicate your preferences below:

            Beechwood Farms:             ______

            Indiana County: ______

            Washington County:            ______

Beginning in 2012, the WMPC Newsletter will be available in full color electronically by e-mail or in black and white by US Postage. Please indicate your preferences below:

Newsletter Options:

            Electronic (e-mail):    ____

            Hardcopy (US Postage)            ____

Future WPMC Information:

            Electronic (e-mail):    ____

            Hardcopy (US Postage)            ____

3.2012

Signing and dating the release is an absolute requirement for membership. Unsigned or undated membership applications will be returned.

Western Pennsylvania Mushroom Club

Release and Indemnification Agreement

This Release and Indemnification Agreement (the "Agreement") is entered into by and between the Western Pennsylvania Mushroom Club, as it is presently organized and may be later structured ("WPMC") and the undersigned Member (the "Member") on this ____ day of _____________________, 20__. 

WHEREAS, WPMC is a non-profit educational organization that has as its principal purpose the sharing of mushroom-related information among its members; and

WHEREAS, all officers, directors, identifiers and members serve WPMC in a voluntary capacity and receive no remuneration for their services; and

WHEREAS, in cases where WPMC charges a fee for its forays, walks, lectures and other events (collectively "WPMC Events"), it is doing so only to cover its direct costs and does not operate in a for-profit capacity; and

WHEREAS, the Member understands that there is inherent and unavoidable risk in outdoor activities relating to hunting and consuming wild mushrooms. These risks include but are not limited to the dangers of hiking in difficult terrain, the possibility of misidentifying a wild mushroom, and the possible allergic or toxic reaction that some individuals may have to otherwise edible mushrooms.

NOW THEREFORE, the Member hereby agrees to the following:

1. The Member assumes all risks associated with WPMC Events. The Member expressly acknowledges that it is the Member's sole responsibility to hike safely and to determine whether a wild mushroom may be consumed.
2. The Member releases, holds harmless, and indemnifies the WPMC, its officers, directors, identifiers, and representatives from any and all liability relating to any injury or illness incurred by the Member or the Member's family members as a result of participation in a WPMC Event.

This Agreement shall be governed by the laws of the Commonwealth of Pennsylvania. If any portion of the Agreement is declared for any reason to be invalid or unenforceable, such invalidity shall not affect any other provision of the Agreement. This Agreement shall apply to all current and future WPMC events.

MEMBERS: Signature (if Participant is under age 21, signature of Parent or guardian); please print name.

Signature                        Print Name

1 ______________________________________ 1 ____________________________________

2 ______________________________________ 2 ____________________________________

3 ______________________________________ 3 ____________________________________

4 ______________________________________ 4 ____________________________________

2.2012