Application to join the Flying Dentists Association
First Name _________________________________________________________
Spouse Name ________________________ Type of Practice ______________
Children's Name & Ages _____________________________________________
Office Street Address ______________________________________
Office City, State ____________________ zip ________________
Office Phone _____/_____________
Send Mail to -> HOME ___ OFFICE ___
Home Street Address ________________________________________
Home City, State ______________________ zip ________________
Home Phone _____/_____________
Home Airport _________________________
A/C Number N-_________ A/C Make_____________ Model _______
Date of Birth ___/___/___ Year Started to Fly ______________
Ratings _________________ Does your Wife Have a License ___
What flying activities interest you? _______________________
Fax Phone ____/_________ E-mail address ____________________
How do you use your A/C in your Profession? ________________________
Our web site has a section for members only,
that lists name address, email address etc.
Do you want your information to be placed on our site with the other members?
Yes I want to be listed in our FDA Roster on the web _____
No I do not want to be on our FDA Roster on the web _____
If you decide to be included in our web Roster,
Paul Hoffman will tell you how to access the roster.
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I hereby make application for membership in the Flying Dentist
Association. I agree to abide by the bylaws and to pay dues as
required. I have enclosed $90.00 to cover my dues and the initiation fee.
Signed______________________________________________________________
Mail To: Flying Dentist Association
Judith Salisbury FDA Exec. Secretary
10032 Wind Hill Drive
Greenville, IN 47124-9673
There are 2 easy ways to join.
1) email our Exec Secretary
Send an email to JSalis913@aol.com
In the body of the message say: Want to Join
She will email you a copy of the above application
which you need to fill out and return with a check.
2) Copy the above application, and the waiver, listed below.
Sign and send them with a check. To
Flying Dentist Association
Judith Salisbury FDA Exec. Secretary
10032 Wind Hill Drive
Greenville, IN 47124-9673
Copy this application onto the clip board, and then paste it from the clip
board onto your word processor so you can fill in the blanks. If you need detailed
instructions, see below.
To copy the application, run the cursor to the top of this page
hold down the shift key, and with the mouse run the cursor to the
bottom of the page. This will select, and highlight the entire
page. Once the page is selected (i.e. highlighted) if you press
Control and C this will paste the selected text onto the clipboard.
Then you need to open you favorite word processor, start a new
blank page and paste the clip board onto your blank page.
If you are using Microsoft Word, all you need to do is
press the windows key on your key board to bring up the start
menue, press P to get the programs, and then select Microsoft
Word. When it starts just paste in the application form
by pressing the control key and V. All that is left is to
fill out the form print it and send it in with your payment.
If you have any questions about this,
give me a call: Paul Hoffman 520-648-5551
or send an email hoffman183@cox.net
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FDA Member=s Name _________________________________________
FLYING DENTISTS ASSOCIATION
RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT
FOR MEMBERS AND SPOUSES
IN CONSIDERATION of participating in meetings,
transportation and areas of activities sponsored by The Flying Dentists
Association, and its representatives, EACH OF THE UNDERSIGNED, for
himself/herself, his/her personal representatives, heirs and next of kin:
1.
HEREBY AGREES AND ACKNOWLEDGES, REPRESENTS AND WARRANTS THAT HE/SHE has,
or will immediately upon entering and will continuously thereafter, inspect such
restricted area or areas and all portions thereof which he/she enters and with
which he/she comes in contact, and he/she does further warrant that his/her
entry upon such restricted area or areas constitutes an acknowledgment that
he/she has inspected such restricted area or activity and that he/she finds and
accepts the same as being safe and reasonably suited for the purposes of his/her
use, and he/she further agrees and warrants that if, at any time, he/she is in
or about restricted areas or activities and he/she feels anything to be unsafe,
he/she will immediately advise the FDA representative in charge of such event
and will leave the FDA meeting.
2.
HE/SHE HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE THE
FLYING DENTISTS ASSOCIATION AND ALL REPRESENTATIVES, all for the purposes herein
referred to as AReleasees,@
from all liability to the undersigned, his/her personal representatives,
assigns, heirs, and next of kin for any and all loss or damage, and any claim or
demands therefor on account of injury to the person or property or resulting in
death of the undersigned, whether caused by the negligence of the AReleasees@
or otherwise while the undersigned is in or upon the restricted area.
3.
HE/SHE HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the AReleasees@
and each of them from any loss, liability, damage, or coast they may incur due
to the presence of the undersigned in or upon the restricted area or activity,
whether caused by the negligence of the AReleasees@
or otherwise.
4.
HE/SHE HEREBY ASSUMES FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY,
DEATH OR PROPERTY DAMAGE due to the negligence of AReleasees@
or otherwise while in or upon the restricted area or activity.
EACH OF THE UNDERSIGNED expressly acknowledges that
his/her activities could be dangerous and involve the risk of serious injury
and/or death and/or property damage. EACH OF THE UNDERSIGNED further expressly
agrees that the foregoing release, waiver, and indemnity agreement is intended
to be as broad and inclusive as is permitted by the law of the state of the
activity and that if any portion thereof is held invalid, it is agreed that the
balance shall, notwithstanding, continue in full force and effect.
THE UNDERSIGNED HAS
READ AND VOLUNTARILY SIGNS THE RELEASE AND WAIVER OR LIABILITY AND INDEMNITY
AGREEMENT, and further agrees that no oral representations, statements or
inducements apart from the foregoing written agreement have been made.
_________________
_______________________________
________________________________
Date
Member Name (print)
Member Signature
_________________
______________________________
_________________________________
Date
Spouse Name (print)
Spouse
Signature
FLYING DENTISTS ASSOCIATION
MINOR RELEASE AND WAIVER OF LIABILITY AND INDEMNITY AGREEMENT
IN CONSIDERATION of being allowed to attend The
Flying Dentists Association (FDA) meetings, the parent(s) and/or legal
guardian(s) of the minor named below agree:
5.
The parent(s) and/or legal guardian(s) will instruct the minor that prior
to attending FDA meetings, he or she should inspect the property, and if he or
she believes anything is unsafe, he/she should immediately advise The Flying
Dentists Association representative in charge.
6.
I/We fully understand and acknowledge that:
1.
There are risks and dangers associated with attending FDA meeting which
could result in bodily injury, partial and/or total disability, paralysis and
death.
2.
The social and economic losses and/or damages, which could result from
those risk and dangers described above could be severe.
3.
These risks and dangers may be caused by the action, inaction or
negligence of the person or the action, inaction or negligence of others,
including, but not limited to, the AReleasee@
named below.
4.
There may be other risks not known to us or are not reasonably forseeable
at this time.
7.
I/We accept and assume such risks and responsibility for the losses
and/or damages following such injury, disability, paralysis or death, however
caused and whether caused in whole or in part by the negligence of the AReleasee@
named below.
8.
I/WE HEREBY RELEASE WAVE, DISCHARGE AND COVENANT NOT TO SUE THE FLYING
DENTISTS ASSOCIATION, for the purposes herein referred to as AReleasee,@
from all liability to the undersigned, my/our personal representatives, assigns,
executors, heirs and next of kin for any and all claims, demands, losses or
damages on account of any injury, including but not limited to death or damage
to property, caused or alleged to be caused in whole or in part by the
negligence of the AReleasee@
or otherwise.
9.
On behalf of the minor and individually, the undersigned parent(s) and/or
legal guardian(s) for the minor executes this Waiver and Release. If, despite
this release, the minor makes a claim against the AReleasee,@the
parent(s) and/or legal guardian9s) will reimburse the AReleasee@
and its insuring company for any money which it has paid to the minor, or on
his/her behalf, and hold it harmless.
I/WE HAVE READ THE
ABOVE WAIVER AND RELEASE, UNDERSTAND THAT I/WE GIVE UP SUBSTANTIAL RIGHTS BY
SIGNING IT VOLUNTARILY WITHOUT INDUCEMENT.
___________________
__________________________________________
Date
Name of Minor (please print)
___________________
__________________________________________
Date Signature(s) of Parent(s)/Legal Guardian(s)