THIS IS NOT AN ON-LINE SUBMISSION FORM-PLEASE COMPLETE, PRINT THIS FORM AND MAIL

2018 Nebraska 4-D Membership Application

One membership form must be completed for EACH member

All race information and results will be found on the website  www.ne4d.com.

If you do not have internet you can receive a monthly mailing from April-October 

Open 4-D Membership - $30.00 ($35.00 after July 1 of current year) 

                  Eligible to compete in Open Division.

Family 4-D Membership - $20.00 per additional person ($25.00 after July 1 of current year)

                  (Must have one full paying Open Membership, then each additional family member, residing at the same address,

                  qualifies for the rate.  Open Division Eligibility.)

Pee Wee/Youth 4-D Membership - (13 and under) - $15.00 ($20.00 after July 1 of current year)

                  (Eligible to compete in the Youth Division.)

 

Nebraska 4-D Release Agreement

By making an application to join the Nebraska 4-D, Applicant agrees to participate at their own risk.  Applicant here by releases and discharges the Nebraska 4-D, its Board of Directors, representatives, employees, and agents for all liability, loss, claims, damages and expenses for injuries to person, property, reputation, or financial condition as a result of, or in any way relation to Applicants participation, or failure to participate, in an Nebraska 4-D event, whether caused by negligence, by arena or facility conditions, by the conduct of show management, or the administration of failure to enforce any Nebraska 4-D rule, regulation, bylaw, guideline, or otherwise.  Applicant further agrees that by signing this application, he/she completely releases the Nebraska 4-D from any liability, including negligence.  Applicant voluntarily chooses to participate and abide by all rules and regulations of the Nebraska 4-D.

 

Signed  _______________________________________________________________ Date _______________             

              _______________________________________________________________ Date _______________

               (Parent or Guardian if applicant is a minor)

 

 Nebraska 4-D Membership Information

 

ONE MEMBERSHIP FORM MUST BE COMPLETED FOR EACH MEMBER.

 

Name  

Address 

City State

Zip Phone SS#

E-mail    Date

 Are you a

 New Member

 Renewal Member   

 Sex:    M  F   

 For youth:

 DOB

 

ALL APPLICATIONS MUST BE SIGNED AND COMPLETED.

 

INCOMPLETE APPLICATIONS WILL BE RETURNED.

Send completed application to:

Nebraska 4-D

44080 Rd 796

Broken Bow, NE 68822

 

(Tear here)

 

Date Joined

 

Name

 

Authorization ___________________

 

Amount Paid $___________________

Nebraska 4-D

c/o Marlene McGaughey

44080 Rd 796

Broken Bow, NE 68822

Board of Directors

Secretary/Members..........Marlene McGaughey (308) 872-6998

Finals/Awards..........Lee Ann Kucera (308) 750-7860

Finals/Awards..........Samantha VonHeeder (402) 760-3168

Scheduling..........Beth Baxter (308) 440-3776