EmailMeForm
Professional Senior Rodeo Association
2021-22 Membership Form
ONLY ONE MEMBERSHIP PER FORM.
PLEASE DOUBLE CHECK YOUR MATH
Please make your checks to the PSRA and mail
To:
Brenda Reay
1477 Hwy 201
Adrian, OR. 97901
Feel free to call at 208-250-6361 if you need assistance.
Name
First
Last
Email
Social Security Number
*
Phone
*
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Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Gender
Male
Female
Date of Birth
*
MM
/
DD
/
YYYY
Jacket Size
Women's Small
Womens's Medium
Women's Large
Women's X-Large
Men's Small
Men's Medium
Men's Large
Men's XLarge
Men's XXLarge
Age Group
40-50
50-60
60 +
68+
Membership Type
EARLY BIRD MEMBERSHIP IS DUE BY FEBURARY 28, 2022
Early Bird Membership $150.00
Permit ( Three Per Season) $25.00
Timer $20.00
Secretary $20.00
Stock Contractor $50.00
Judge $20.00
Photographer $20.00
How Long Have You Rodeoed
List each, a description, the level, and number of years of involvement.
Other Activities You Enjoy?
List your organizations, position, description of the activities you are involved in other than rodeo.
RETURNING MEMBER
*
Yes
No
ROOKIE MEMBER
*
Yes
No
May we publish your information for a membership directory?
*
Yes
No
Would you like to donate to the crisis fund?
*
Yes $5.00
No
Would you like a monthly copy of the Rodeo News?
*
Yes
No
Do you understand and agree to the terms listed above?
Yes, I understand and agree to the terms listed above.
One Time Office Fee
*
$10.00
THIS IS A RELEASE OF LIABILITY. BY BECOMING A MEMBER OF THE PSRA, YOU ARE AGREEING TO RELEASE ALL PARTIES FROM LIABILITY. PLEASE READ THIS PROVISION CAREFULLY. Members acknowledge that rodeo events, including PSRA-sanctioned events, are inherently dangerous activities. Members further acknowledge that participation in a PSRA-sanctioned event (whether as a competitor, independent contractor, official, laborer, volunteer or observer) exposes the participant to substantial and serious hazards and risks of property damage, personal injury and/or death. Each Member, in consideration of his membership in the PSRA
and his being permitted to participate in a PSRA-- sanctioned event in any capacity, does by such membership and participation agree to assume such hazards and risks. Each Member further agrees to discharge, waive, release and covenant not to sue PSRA , all A sponsors, all Members (including, without limitation, contestants, stock contractors, Rodeo Committees, Rodeo Producers and Contract Personnel), and any other PSRA- sanctioned event production entity (and each party’s respective officers, directors, employees and agents), from all claims, demands and liabilities for any and all property damage, personal injury and/ or death arising from such Member’s participation in a PSRA-sanctioned event. This discharge, waiver and release includes claims, demands and liabilities that are known or unknown, foreseen or unforeseen, future or contingent, and includes claims, demands, and liabilities arising out of the negligence of the parties so released by such Member. Furthermore, where permitted by applicable law, this discharge, waiver and release also includes claims, demands and liabilities arising out of the gross negligence or willful and wanton negligence of the parties so released. This discharge, waiver and release also includes claims, demands, and liabilities by a Member for indemnities and contributions arising from property damage, personal injury and/or death to a third party. In the event that any provision of this discharge, waiver and release is determined to be invalid for any reason, such invalidity shall not affect the validity of any of the other provisions, which other provisions shall remain in full force and effect as if this discharge, waiver and release had been executed with the invalid provision eliminated. The undertakings and covenants of the foregoing provisions shall be binding upon each Member, his or her heirs, legal representatives, successors, and assigns. Each Member (including, without limitation, contestants, stock contractors, Rodeo Committees, Rodeo Producers and Contract Personnel) agrees to indemnify and save and hold harmless PSRA, and all PSRA sponsors from any and all claims, demands and liabilities for any and all property damage, personal injury and/or death asserted by a third party (defined as any party other than the Member , PSRA sponsor) and arising from such Member’s participation in a PSRA-sanctioned event.
I understand above information
Signature
*
Clear
