Tri State Chapter
Membership Enrollment Form
Name:
Street Address:
City: State: Zip Code:
Phone: Daytime Phone: Email:
National HOG Number: Expiration Date:

I recognize that while my local chapter may be affiliated with the Harley Owners Group ( "H.O.G." ), 
it remains a separate, independent entity responsible for its own actions.

I also agree that Harley-Davidson, Inc., the Harley Owners Group, Hannum's Harley-Davidson, 
and the Tri-State Chapter of the Harley Owners Group, Inc., (hereinafter the "Released Parties"), 
shall not be liable or responsible for damage to property or any injury to persons including myself 
during any H.O.G. or H.O.G. chapter activities even where the damage or injury is caused by 
negligence (except willful neglect).  I understand that and agree all Harley Owners Group members 
and their guests participate voluntarily and at their own risk in all H.O.G. and H.O.G. chapter activities.  
I release and hold harmless the Released Parties for any injury or loss to my person or property 
which may result there from.  I understand that this means that I agree not to sue the Released 
Parties for any injury resulting to myself or my property in connection with any H.O.G. or H.O.G. 
chapter activities.

I HAVE READ THE ABOVE RELEASE
 Local Chapter Dues $ 20.00

MEMBER SIGNATURE: ______________________________________ DATE:

________________________________________

________________________________________
For Chapter Use Only:
Dues Received By: __________ Date: __________ Dues Paid By: ______ Cash ______ Check
Computer Records Updated _____________ National H.O.G. Card Seen By: ______________

Please print and mail with payment to:

 Tri State HOG 
P.O. Box 17
Media, PA 19063