Name 1 __________________________________________________________________
Name 2 __________________________________________________________________
Name 3 __________________________________________________________________
Address __________________________________________________________________
City/State/Zip ____________________________________________________________
Phone _______________________________ E-mail ______________________________
Knowing the risks, I (we) agree to assume the risks, and agree to release, hold harmless, and to indemnify the Western Pennsylvania Mushroom Club, and any of its officers or members, from any and all legal responsibility for injuries or accidents incurred by myself or my family during, or as a result of, any mushroom identification, field trip, excursion, meeting or dining sponsored by the club.
Signature ______________________________________ Date: _____________________
Signature ______________________________________ Date: _____________________
Signature ______________________________________ Date: _____________________
For more information, contact foray co-chairs: Dick Dougall 412-486-7504, Mush2prof@verizon.net
John Stuart 724-443-6878, jons2art@comcast.net