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THE MIDWEST JACK RUSSELL TERRIER CLUB MEMBERSHIP APPLICATION

Membership in the MWJRTC includes: seasonal newsletters, discounts on certain club activities,one free Classified Ad in our newsletter (business card size, up to 5 lines), and a chance to meet fellow Jack Russell enthusiasts.
Check ONE: ____ SINGLE ADULT ____ TWO ADULTS (living in same household)____ FAMILY (includes children under 21yrs of age, same mailing address as adult)AGES OF CHILDREN ___________
NAME (PLEASE PRINT): __________________________________________________
NEW MEMBER___RENEWAL___
STREET ADDRESS:___________________________________________
CITY, STATE, ZIP:_____________________________________________
PHONE: (_____ )____________________________
E-MAIL ADDRESS:____________________________________
Would you be interested in serving on a committee? _____YES (if yes someone will contact you) _____NO
Would you be interested in helping with Russell Rescue? Such as fostering or adopting? _____YES _____NO
How did you hear about us?____________________________________________________
YEARLY MEMBERSHIP DUES ARE $25.00, JANUARY 1st TO DECEMBER 31st.
Applications received during Nov. or Dec. will cover membership through Dec. of the following year.

APPLICATION FORM MUST BE SIGNED IN BOTH PLACES
Membership application must include check payable to the MWJRTC and sent to:
Skiff Weeden, Club Secretary, 232 Harding Ave, Libertyville, IL 60048
Persons applying for membership in the MWJRTC (or renewing a current membership) and members of their immediate family shall not be a member of any conflicting JRT organization as denied by the JRTCA/MWJRTC. Applicants shall not register their JRT's with any conflicting organization or any all-breed kennel club. Membership may be terminated, suspended or refused by the MWJRTC Officers for any conduct which may be considered likely to prejudice or damage the image of or interfere with the efficient running of the Club, or compromise the breed standard in any way.

I hereby apply for membership in the Midwest Jack Russell Terrier Club and certify that I do not belong to any conflicting JRT organization, nor do I register my terriers with any all-breed kennel club.

Signature (s) ________________________________________ Date______________
RELEASE OF LIABILITY
The person who signs release assumes all liability for all participating family members.
In consideration of my participation as a member (in any category)of the Midwest Jack Russell Terrier Club (the "Club") at meetings, seminars, fun days, trials and any other events, I hereby waive any and all claims for, and remise and release the Club, its members, officers, directors,and/or any other participants from any and all liability for damages to person or property, accidents, or injuries caused by or in any way arising out of or related to participation in any "Club" activities including the period of time immediately prior there to and immediately thereafter the conclusion of the activity.
Each signer understands that by participation he or she is a joint venture participant and assumes all risks of liability to themselves occasioned by
this participation.
The release and waiver shall be effective from the date of signing.
Signature(s)________________________________________________Date __________
******APPLICATION FORM MUST BESIGNED IN BOTH PLACES******
---------------------------------FOR OFFICIAL USE ONLY--------------------------------------------------------
DATE RECEIVED _____________AMOUNT PAID ______________ CASH ( ) CHECK ( ) CHECK #_____
Revised 11/30/05