Author: Zaxxis

BHPC Membership Page 1 of 2
Application
Application will not be processed unless
Disclaimer on other side is Signed
Subscription per year - $50.00 over 18 years old
$100.00 One Time Claim Fund Donation Fee
$150 Total
Date: Month/______________ Day/__________ Year/____________
PLEASE PRINT CLEARLY
Names-
Last: ____________________ First: ________________________
Last: ____________________ First: ________________________
Name & Age of Children (under 18 years old)
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
PLEASE PRINT CLEARLY
Mailing Address:
Street _________________________________Apt / Lot #________ PO Box ___________
City ___________________________________________________
State__________________________________________________
Zip Code__________________
Telephone # ( ______ ) ______ - ________
Cell Phone # ( ______ ) ______ - ________
e-Mail Address _______________________________________________________________
______________________________________________________________
Check here if you would like to get your Newsletter in your e-Mail
Referred by or How did you hear about our Club? _____________________________________
The Black Hills Prospecting Club reserves the right to refuse
or revoke membership to anyone at any time.
NOTE:
Subscriptions are for and include:
Monthly Newsletter and/or Postcard. Club claims, Original 07/02/2002
Membership ID Cards and it helps keep the Club's Website going Revised 09/17/2010

Black Hills Prospecting Club of South Dakota Page 2 of 2
Disclaimer
Release in full of any and all claims
For and in consideration of being a member of the Black Hills Prospecting Club of South Dakota (BHPC of SD):
I / WE do hereby acquit and forever discharge the BHPC of SD, it's members, Directors, Officers, and any other persons, Firms, Entities, or Corporations, of any and all actions, claims, demands, costs, loss of service growing out of any and all known and unknown personal injuries and property damage resulting or from the result of any accidents that could occur on any of the club owned or leased properties or at any club sponsored activity on the property of others and not club owned. Also understand you are responsible for the actions of your guests!
I / WE, the undersigned, do hereby state that I / WE have not been influenced to any extent whatsoever in making this release by any representations or statements regarding said injuries, or liability, or any other matters made by the club, it's members, Directors, Officers, hereby released or by any person(s) representing or acting for them. This release contains the entire agreement between the parties hereto, and the terms of the release are binding and contractual.
I / WE further state I / WE have carefully read and understand the foregoing release and know the contents thereof and I / WE sign the same as MY / OUR free act.
PLEASE PRINT CLEARLY
Print Name:________________________________________________________________
Signature and Date:_________________________________________________________
Print Spouse Name:_________________________________________________________
Signature and Date:_________________________________________________________
Any Member(s) that violate BHPC Rules or Claim Policy may have their membership revoked. Please read all rules and claim policy concerning the claims owned by BHPC of South Dakota.
Make Check or Money Order payable to:
Black Hills Prospecting Club
Mail completed Application
and Signed Disclaimer to:
Black Hills Prospecting Club
PO Box 386
Black Hawk SD 57718

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