Application for Membership – Fernandina Pirates Club

First Name

Last Name

Preferred Pirate Name / Alias (Optional)

Date of Birth

Email Address

Phone Number

Street Address

City

State

Zip Code

Emergency Contact Full Name

Should not reside with you.

Emergency Contact Phone Number

Relationship to Applicant

Acknowledgement of Club Rules and Policies

I acknowledge that I have received and read a copy of the General Safety Rules, Firearms Regulations, Bylaws, Policies and Procedures and any other rules the Club may promulgate in the future. I understand and agree to abide by any such rules.

Indemnification and Hold Harmless Agreement

I fully agree to personally accept responsibility and liability for my actions and to indemnify, hold harmless and defend the Club from any loss, damage, expense, claim, cause of action and/or liability that may arise from any action I may take while participating in a Club sanctioned event or at any public or private event or occurrence at which I hold myself out to be a member of the Club.

Authorization for Background Check

By agreeing, I give the Fernandina Pirates Club permission to do a background check on me before being voted in as a Pirate. I understand that the purpose is to reveal to the Club if I have been convicted of being a pedophile, sexual predator, child or spousal abuser, have excessive DUI’s, excessive disorderly conduct charges or convicted of any felony that could negatively affect the reputation of the Fernandina Pirates Club or be a danger to any other member or the public.

Electronic Signature (Type Full Name)

By typing your name, you attest all information is true and you agree to all terms outlined above.