West Central Georgia Flying Club, Inc
Membership Application


PERSONAL INFORMATION
Name     
Address             Date of Birth (MonthDay Year)
City       ,State Zip-
Home Phone  (-          Work Phone (-  
Cell Phone     (- 
eMail Adderss


EMPLOYMENT INFORMATION
Employer 
Address   
City         ,State Zip-


PREVIOUS FLYING & MEDICAL INFORMATION
Certificate Number  Date BFR Due (MonthDay Year)
Medical Class         Date Issued (MonthDay Year)
Limitations            
Ratings                 
Type Aircraft Flown 
LOGGED PILOT HOURS
Total  Multi  Retract  Tail Wheel  Last 12 Months 

Do you have any physical impairments, waivers, limitations or conditions on you FAA medical certificate?YesNo
Has your FAA or Military certificate ever been suspended?                                                                     YesNo
Have you ever been cited for violation of a FAR?                                                                                    YesNo
Have you ever been involved in a aircraft accident?                                                                                  YesNo
Have you ever been convicted of or plead guilty to drunken driving, or felony?                                         YesNo


EMERGENCY INFORMATION
Person to Contact    Relation
Phone Number #1  (-  Phone Number #2  (-


For Flight training, each applicant must present proof of Citizenship to their flight instructor in the form of a copy of Current US Passport or original copy of Birth Certificate with raised letters showing on Seal and Gov issued ID. These must be presented prior to starting training for any Flight Certificate except Flight Reviews.

I hereby apply to the West Central Georgia Flying Club and certify that all information is correct.

Signature____________________________________             Date____________________


West Central Georgia Flying Club, Inc
Statement of Understanding

The Undersigned does hereby agree to observe and abide by all regulations of the West Central Georgia Flying Club Inc., and to acquaint himself/herself thoroughly with the local field rules of any and all airport or strips where the Club equipment is operated.  By signing, he/she acknowledges he/she has received, read and understands the Club's By-Laws and Flight Rules.

  Signature__________________________________                     Date___________________

West Central Georgia Flying Club, Inc    
Covenant Not To Sue, Hold Harmless and Indemnity Agreement

I, __________________________________________ am about to participate voluntarily in various activities, including flying activities, of the West Central Georgia Flying Club as a pilot, student pilot, copilot, instructor or passenger In consideration of the Flying Club permitting me to participate in these activities, I, for my heirs, administrators, executors, and assignees, hereby covenant and agree that I will never institute, prosecute, or in any way aid in the institution or prosecution of, any demand, claim, or suit against the West Central Georgia Flying Club and/or its officers, agents, or employees, acting officially or otherwise, for any loss, damage, or injury to my person (including death), or my property which may occur from any cause whatsoever as a result of participation in the flying club. If I or my heirs, administrators, executor, and assignees should demand, claim, sue, or aid in any way in such a demand, claim, or suit, I agree to indemnify the West Central Georgia Flying Club for all damages, expenses, and costs it may incur as a result thereof.

I understand and agree I am assuming the risk of death, any personal injury or property damage to me that may result while participating in flying club activities, including such injuries or damage that may be caused by the negligence of the West Central Georgia Flying Club.
I also understand and agree I may be held liable for any damage or loss to the West Central Georgia Flying Club which is caused by my gross negligence, willful misconduct, or fraud.

The term “West Central Georgia Flying Club” as used here includes the West Central Georgia Flying Club including individual members and any officer, agent or employee of the West Central Georgia Flying Club/or the Flying Club, acting officially or otherwise.

 
Signature__________________________________                     Date___________________