Application for Membership
Names and dates of birth of household members to be involved in exchanges.
NAME(s) Year of Birth
_________________________________________________________________________ ______________
__________________________________________________________________________ ______________
__________________________________________________________________________ ______________
Address _________________________________________________________ Ann Arbor, 48103
Phone:_______________________email:__________________________________Date_________
Check the services below which you might offer to other members
and circle those you think you might need:
___CARE – Respite, Illness, Infant ___COMP – Computer Assistance (type)
___DRIVE – Errands, Car Pools ___L&G– Lawn & Garden Care
___MEALS – Preparation, Sharing ___REP – Simple Home Repairs
___SEW – Sewing, Mending, Knitting ___S&L - Snow or Leaf Removal ____SOC – Social (games, music, visit, etc) ___ TCH - Give lessons on special skills
___VAC – Vacation Care of Plants, Pets ____Other _____________________
The Initiation Fee is $20 plus dues of $10 per year. ($5 if enrolling after July 1st) Mail completed application with check payable to Dexter-Miller Community to: DEXMIL, 2113 Arborview Blvd, Ann Arbor, MI 48103
2012 Board of Directors
Scott Hale 222-0250 hooah175@hotmail. om
JoAnn Marcoux Treasurer 260-2009 jmarcoux@umich.eduSally Mitani Membership Scty 996-2731 sally@mitanishoeworks.com
Melinda Todd no phone galacticstitcher@gmail.com
Tom Weisskopf President 929-2899 tomw@umich.edu
Kathy West Corresp. Scty. 994-1493 kathywes@umich.edu
To avoid insurance costs, members will be asked to sign a liability waiver indicating they give up the right to sue other members for accidents or damages occurring while helping each other. Signing the waiver is optional but other members are less likely to agree to service exchanges with those who have not signed.
LIABILITY WAIVER
IN CONSIDERATION of membership in the DEXTER-MILLER COMMUNITY and participating in the free exchange of assistance, goods and services among members (“Activity”) I, for myself and for personal representatives, assigns, heirs, and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of Exchange Support and Assistance Activities with fellow members and that on occasions I may willingly invite or ask other members to enter into my home and personal property in order to assist me and my household in a variety of household activities, repairs and needs. I further agree and warrant that if at any time I believe conditions or activities to be unsafe or damaging , I will immediately discontinue further participation in that Activity by both myself and others acting in my behalf.
2. FULLY UNDERSTAND THAT: (a) SUCH MUTUAL ASSISTANCE ACTIVITIES COULD INVOLVE RISKS AND DANGERS OF SERIOUS BODILY INJURY AND/OR PROPERTY DAMAMGE ("RISKS"); (b) these Risks and dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the Activity, the condition in which the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISK AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation and the assistance provided by the invited member of the DEXTER-MILLER COMMUNITY
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the DEXTER-MILLER COMMUNITY, their respective administrators, directors, agents, officers, members, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owner and lessors of premises on which the Activity takes place, (each considered one of the "RELEASEES" herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT REPAIR OPERATIONS. AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT, I, or anyone on my behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost which may incur as the result of such claim.
I have read this agreement, fully understand its terms, understand that I give up substantial rights by
signing it and sign it freely and without inducement or assurance of any nature and intend it to be a
complete and unconditional release of all liability to the greatest extent allowed by law and agree that
if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in
full force and effect.
Participant:s printed name Participant’s signature
______________________________________ ______________________________________
______________________________________ ______________________________________
_____________________________________ ______________________________________ Street Address Phone
__________________________________ __________________________
Ann Arbor, MI 48103 Date ___________________
Parent or Guardian of participants under 18 years of age, must also complete the following additional Release. side.
TO BE COMPLETED IF PARTICIPANT IS UNDER 18 YEARS OF AGE
MINOR RELEASE
AND I, __________________________’S PARENT AND/OR LEGAL GUARDIAN, UNDERSTAND THE NATURE OF DEXTER-MILLER COMMUNITY ACTIVITIES AND THE MINOR’S EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED, IN GOOD HEALTH, AND IN PROPER PHYSICAL CONDITION TO PARTICIPATE IN SUCH ACTIVITY. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS EACH OF THE RELEASEE’S FROM ALL LIABILITY CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON THE MINOR’S ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATION AND FURTHER AGREE THAT IF, DESPITE THIS RELEASE, I, THE MINOR, OR ANYONE ON THE MINOR’S BEHALF MAKES A CLAIM AGAINST ANY OF THE RELEASEES NAMED ABOVE, I WILL HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE, OR COST ANY MAY INCUR AS THE RESULT OF ANY SUCH CLAIM.
__________________________________________ ________________________________
Printed Name of Parent/Guardian: Signature of Parent/Guardian
__________________________________________ ________________________________
Street Address: _____________________________________
ANN ARBOR, MI 48103 Date __________________________
Initiation Fee is $15.00. Dues are $10.00 per year, ($5.00 if enrolling after June 21st)
Mail completed application with a check payable to Dexter-Miller.Community to:
DEXMIL, 2113 Arborview Blvd, Ann Arbor, MI 48103 If paying the fees is a problem
for you, enclose a statement describing your circumstances to be considered for a fellowoship..
For comments, questions, or more information complete the form below
NAME(s) Year of Birth
_________________________________________________________________________ ______________
__________________________________________________________________________ ______________
__________________________________________________________________________ ______________
Address _________________________________________________________ Ann Arbor, 48103
Phone:_______________________email:__________________________________Date_________
Check the services below which you might offer to other members
and circle those you think you might need:
___CARE – Respite, Illness, Infant ___COMP – Computer Assistance (type)
___DRIVE – Errands, Car Pools ___L&G– Lawn & Garden Care
___MEALS – Preparation, Sharing ___REP – Simple Home Repairs
___SEW – Sewing, Mending, Knitting ___S&L - Snow or Leaf Removal ____SOC – Social (games, music, visit, etc) ___ TCH - Give lessons on special skills
___VAC – Vacation Care of Plants, Pets ____Other _____________________
The Initiation Fee is $20 plus dues of $10 per year. ($5 if enrolling after July 1st) Mail completed application with check payable to Dexter-Miller Community to: DEXMIL, 2113 Arborview Blvd, Ann Arbor, MI 48103
2012 Board of Directors
Scott Hale 222-0250 hooah175@hotmail. om
JoAnn Marcoux Treasurer 260-2009 jmarcoux@umich.eduSally Mitani Membership Scty 996-2731 sally@mitanishoeworks.com
Melinda Todd no phone galacticstitcher@gmail.com
Tom Weisskopf President 929-2899 tomw@umich.edu
Kathy West Corresp. Scty. 994-1493 kathywes@umich.edu
To avoid insurance costs, members will be asked to sign a liability waiver indicating they give up the right to sue other members for accidents or damages occurring while helping each other. Signing the waiver is optional but other members are less likely to agree to service exchanges with those who have not signed.
LIABILITY WAIVER
IN CONSIDERATION of membership in the DEXTER-MILLER COMMUNITY and participating in the free exchange of assistance, goods and services among members (“Activity”) I, for myself and for personal representatives, assigns, heirs, and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of Exchange Support and Assistance Activities with fellow members and that on occasions I may willingly invite or ask other members to enter into my home and personal property in order to assist me and my household in a variety of household activities, repairs and needs. I further agree and warrant that if at any time I believe conditions or activities to be unsafe or damaging , I will immediately discontinue further participation in that Activity by both myself and others acting in my behalf.
2. FULLY UNDERSTAND THAT: (a) SUCH MUTUAL ASSISTANCE ACTIVITIES COULD INVOLVE RISKS AND DANGERS OF SERIOUS BODILY INJURY AND/OR PROPERTY DAMAMGE ("RISKS"); (b) these Risks and dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the Activity, the condition in which the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISK AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation and the assistance provided by the invited member of the DEXTER-MILLER COMMUNITY
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the DEXTER-MILLER COMMUNITY, their respective administrators, directors, agents, officers, members, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owner and lessors of premises on which the Activity takes place, (each considered one of the "RELEASEES" herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT REPAIR OPERATIONS. AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT, I, or anyone on my behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage, or cost which may incur as the result of such claim.
I have read this agreement, fully understand its terms, understand that I give up substantial rights by
signing it and sign it freely and without inducement or assurance of any nature and intend it to be a
complete and unconditional release of all liability to the greatest extent allowed by law and agree that
if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in
full force and effect.
Participant:s printed name Participant’s signature
______________________________________ ______________________________________
______________________________________ ______________________________________
_____________________________________ ______________________________________ Street Address Phone
__________________________________ __________________________
Ann Arbor, MI 48103 Date ___________________
Parent or Guardian of participants under 18 years of age, must also complete the following additional Release. side.
TO BE COMPLETED IF PARTICIPANT IS UNDER 18 YEARS OF AGE
MINOR RELEASE
AND I, __________________________’S PARENT AND/OR LEGAL GUARDIAN, UNDERSTAND THE NATURE OF DEXTER-MILLER COMMUNITY ACTIVITIES AND THE MINOR’S EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED, IN GOOD HEALTH, AND IN PROPER PHYSICAL CONDITION TO PARTICIPATE IN SUCH ACTIVITY. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS EACH OF THE RELEASEE’S FROM ALL LIABILITY CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON THE MINOR’S ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATION AND FURTHER AGREE THAT IF, DESPITE THIS RELEASE, I, THE MINOR, OR ANYONE ON THE MINOR’S BEHALF MAKES A CLAIM AGAINST ANY OF THE RELEASEES NAMED ABOVE, I WILL HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE, OR COST ANY MAY INCUR AS THE RESULT OF ANY SUCH CLAIM.
__________________________________________ ________________________________
Printed Name of Parent/Guardian: Signature of Parent/Guardian
__________________________________________ ________________________________
Street Address: _____________________________________
ANN ARBOR, MI 48103 Date __________________________
Initiation Fee is $15.00. Dues are $10.00 per year, ($5.00 if enrolling after June 21st)
Mail completed application with a check payable to Dexter-Miller.Community to:
DEXMIL, 2113 Arborview Blvd, Ann Arbor, MI 48103 If paying the fees is a problem
for you, enclose a statement describing your circumstances to be considered for a fellowoship..
For comments, questions, or more information complete the form below
Comments welcomed.
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