2023 Membership Application – One Time Credit Card Payment

NOTE: Membership Year runs January 1 through December 31. Membership is NOT prorated during the year. Applications received between October 15th and December 31st receive these months free with payment for the new year.

Membership Details
*This information is required
Name*
First Middle Last
Age (Ex: 55)*
Today's Date (not your birthdate)*
MM slash DD slash YYYY
Email*
Phone*
Mailing address or PO Box*
Street Address Address Line 2 City State ZIP Code
Choose a membership option*
*Please note that there is a $20.00 admin fee added at the end of this form for all new members.
Do you need to add additional members?
(Additional to member - $50 for the first additional member) Add your spouse or significant other and/or all dependents living in the same household, ages 17 or under.
Additional Member*
Price:
Additional Member #1
Name*
First Last
Age*
Select Relationship*
- Spouse/Significant Other
- Dependent (minor under 17)
Consent (Spouse/Significant Other)*
I have read the RELEASE and INDEMNIFICATION BELOW. I Understand and Agree to its Contents.
Consent (Dependent/Minor under 17)*
***I hereby swear or affirm that I am the lawful guardian of the above listed minor(s) and have the lawful authority to sign the RELEASE and INDEMNIFICATION BELOW on his/her behalf.
Signature*
Additional Member #2
Name*
First Last
Age*
Select Relationship*
- Spouse/Significant Other
- Dependent (minor under 17)
Consent (Spouse/Significant Other)*
I have read the RELEASE and INDEMNIFICATION BELOW. I Understand and Agree to its Contents.
Consent (Dependent/Minor under 17)*
***I hereby swear or affirm that I am the lawful guardian of the above listed minor(s) and have the lawful authority to sign the RELEASE and INDEMNIFICATION BELOW on his/her behalf.
Signature*
Additional Member #3
Name*
First Last
Age*
Select Relationship*
- Spouse/Significant Other
- Dependent (minor under 17)
Consent (Spouse/Significant Other)*
I have read the RELEASE and INDEMNIFICATION BELOW. I Understand and Agree to its Contents.
Consent (Dependent/Minor under 17)*
***I hereby swear or affirm that I am the lawful guardian of the above listed minor(s) and have the lawful authority to sign the RELEASE and INDEMNIFICATION BELOW on his/her behalf.
Signature*
Additional Member #4
Name*
First Last
Age*
Select Relationship*
- Spouse/Significant Other
- Dependent (minor under 17)
Consent (Spouse/Significant Other)*
I have read the RELEASE and INDEMNIFICATION BELOW. I Understand and Agree to its Contents.
Consent (Dependent/Minor under 17)*
***I hereby swear or affirm that I am the lawful guardian of the above listed minor(s) and have the lawful authority to sign the RELEASE and INDEMNIFICATION BELOW on his/her behalf.
Signature*
Optional Extras
Will you be needing Annual Indoor Range Access?
- Yes, add Indoor Range Access ($30)
- No, I do not need Indoor Range Access
Fee per family is $30 in addition to membership fees.
Annual Indoor Range Access*
Price:
Make A Contribution
Please help us keep the club strong! Contributions to the Pemigewasset Valley Fish and Game Club, Inc. are not deductible as charitable contributions.
General Fund Contribution

The contribution, made in addition to the membership plan, helps to keep the club financially strong and may be used to cover operating costs. Thank you!
Patron Contribution

These contributions are made in addition to the membership plans. Money from patron memberships is used for capital improvements, not to pay regular operating costs. Thank you!
Check your interests
Interests: Select all that apply*
- Archery (Indoor, Outdoor, and 3-D)
- High Power Rifle Shooting
- Smallbore Shooting
- Handgun Shooting
- Pistol League
- Cowboy Action Shooting
- Gong Shoot
- Silhouette (Lever Action) Shooting
- 3 Gun
- Trap or Five Stand Shooting
- Primitive Black Powder Biathlon
- Olympic Biathlon (Year-Round)
- Basic Pistol Training
- Basic Rifle Training
- Basic Shotgun Training
- Metallic Cartridge Reloading
- Shotshell Reloading
- Range Safety Officer Program
- Women On Target Pistol
- Women On Target Rifle
- Women On Target Shotgun
- Civilian Marksmanship Program (CMP)
- Marksman Qualification Program (MQP)
- Serve On a Committee
- Serve On the Board of Directors
- Tuesday’s AM Work Party: Club Maintenance (May through October)
Volunteer some of your time! Please list events at which you can help, or skills you can contribute:
Billing Details
*This information is required
Billing Address*
Same as address above

Street Address Address Line 2 City State ZIP Code
Secure Credit Card

Card Holder*

Card Number*

Card Expiration*

Card CVV*
Release Waiver for Primary Applicant*
I Have Read the *BELOW* RELEASE and INDEMNIFICATION. I Understand and Agree to its Contents.
LIABILITY RELEASE, INDEMNIFICATION & ASSUMPTION OF RISK (“RELEASE”)

Pemigewasset Valley Fish and Game Club, Inc. (“PEMI”), a nonprofit corporation (Must be completed by all individuals upon entry to PEMI property & prior to any activity at PEMI.)

1. In consideration of being allowed on the premises of PEMI or to participate in any activities at PEMI I hereby voluntarily agree to assume any and all risks associated with shooting at PEMI, including gross negligence. I understand the risks and hazards involved. Shooting may be considered a dangerous activity, with the risk of potentially life threatening injuries and potential exposure to lead and airborne lead particles. I assume the risk of any and all injuries I may suffer due to the physical condition of PEMI including all driveways, sidewalks, and pathways on which I may walk, the negligence of PEMI, equipment failures, defective equipment, acts of God & the acts or omissions of shooters or others who may be at, on, or near, PEMI, whether with or without permission of PEMI. I agree to indemnify and hold PEMI harmless for any injuries I may suffer. I hereby consent to receive any medical treatment which may be deemed advisable in the event of injury, accident and/or illness I may suffer during the activities at PEMI and I agree I shall be responsible for the payment of same.

2. I understand there will be other persons shooting, and/or carrying firearms at PEMI and I agree to act prudently and carefully to avoid causing them any injury. I certify that I am, or will be, familiar with the safe use and operation of any firearms I may use while at PEMI. I have read, and I am familiar with the rules of shooting and firearm safety, as well as the specific shooting range rules of PEMI (copies available). On behalf of myself, my estate, my heirs, and assigns, I agree to indemnify and hold harmless PEMI, its Board, employees, agents, representatives, assigns, members, instructors and volunteers from any judgment, actions, attorney’s fees, claims, costs, damages, demands, expenses, liabilities, losses, suits, and procedures regardless of cause. I hereby release PEMI, its Board, employees, agents, representatives, assigns, members, instructors and volunteers from any and all liability, regardless of cause, including gross negligence caused by the acts or omissions of myself or others, for all personal injury I may suffer, up to and including death, and/or disability due to the acts and/or omissions of whatsoever kind and nature, including but not limited to those caused by negligence, including gross negligence that occur because of my presence and participation in activities at PEMI. This RELEASE includes property damage and theft. I will not cause to be brought, nor encourage to be brought, a claim or suit against PEMI. I also agree not to cooperate in the bringing of such a suit or claim except insofar as I may legally be required to do so.

3. I understand that both commercial and noncommercial still, audio/video and/or motion picture, photography & audio recording may occur during my presence at PEMI and as long as I am in the general area, I may be incidentally included in such photography. I hereby grant PEMI, its agents, volunteers, sponsors, beneficiaries, heirs and assigns the right to use my photographic image and video recording(s) of me in the promotion of the shooting sports or PEMI in general as it chooses in its sole discretion without compensation to me. I consent to security audio and video recording in all public space.

4. If any portion of this RELEASE is found to be invalid, the offending portion shall be stricken and the remainder shall remain binding, and in full force and effect. By signing this RELEASE, I hereby waive my right to jury trial and agree to be subject to binding arbitration according to the American Arbitration Association rules.

5. This release shall remain in full force and effect with no expiration for time or other reasons. I understand that it is my responsibility to consult with a physician prior my participation in the shooting sports. I represent that I am physically fit and have no medical, psychological, or other condition which would prevent my full participation in events at PEMI.

6. I hereby certify that I am not legally prohibited from possessing, selling, owning or transferring firearms under New Hampshire or federal law, and I am not a member of an organization that advocates the violent overthrow of the United States Government.
I have read, understand and agree to comply with the Pemigewasset Valley Fish & Game Club's Range Rules*
I have read, understand, and agree to the policy and rules stated above.
Primary Applicant Signature*
Admin Fee*
Price:
Convenience Fee
$0.00
Total
$0.00
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2023 Membership Application – One Time Credit Card Payment

Membership Details

Additional Member #1

Additional Member #2

Additional Member #3

Additional Member #4

Optional Extras

Make A Contribution

Check your interests

Billing Details