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Name(Required)

First Last

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Beach Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Additional Names of People Using Cart (Must be Direct Relative, with Valid Driving License

Winter Address (if applicable)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Year of Use (for example 2026)(Required)

I, the above indicated homeowner/member, hereby request permission of the White Sand Beach Association (WSBA), Inc. Board of Governors (BOG) to operate my Golf Cart Type Vehicle on WSBA roadways during the above-indicated calendar year. I understand that the WSBA BOG have complete authority to grant, deny or revoke my registration at any time should I fail to comply with the requirements of registration or use. I also understand that I must reapply annually. Unless sooner renewed or revoked, this registration will expire at the end of the calendar year. As a condition of approval of registration and use, I hereby agree to the below Conditions of Use, Hold Harmless and Release of Liability, and Requirements of Insurance. A copy of my insurance policy showing coverage and limits is attached to this registration request.(Required)

CONDITIONS FOR USE & OPERATION Pursuant to the authority vested in the White Sand Beach Association, Inc. in Sections 5, 18 and 21 of “An Act Incorporating The White Sand Beach Association, Inc., previously revised on 31 August 2002 (reprinted on 31 August 2008), the following ordinance was approved by the White Sand Beach Association membership on 26 May 2013: Article III, Section 10: Golf Carts and Similar Type Vehicles With specific advance written approval of the White Sand Beach Association (WSBA) Board of Governors (BOG), Golf Carts or similar type vehicles may be permitted to be operated on White Sand Beach Association private roads by association members only. The following restrictions and requirements pertain: 1) The operator must have a valid driver’s license. 2) The vehicle must be properly registered and insured, as applicable, under the laws of Connecticut. Proof must be provided upon request of the BOG. 3) The owner must execute a hold harmless and waiver of liability agreement provided by the WSBA that holds WSBA harmless and waives WSBA liability for any and all personal injury or property damage that may result from the owner’s use of such vehicle on WSBA property. 4) Golf Cart type vehicles may only be used during day light hours. 5) All applicable rules of the road apply. 6) Violations will be enforced per Article II, Section 5 of these ordinances, except that the maximum fine per violation occasion is $250. I understand and will comply with the above-quoted ordinance. I understand, with respect to sub-part (2), that currently neither the Town of Old Lyme or the CT DMV registers Golf Carts and leaves such registration, by CT Gen. Statute, to the local traffic authority. I understand that WSBA is the local traffic authority and that this package constitutes my request to operate and registration of my Golf Cart. I further understand, as pertains to sub-part (5) above, that “all applicable rules of the road,” for the purpose of this request to operate and registration, includes the above-quoted WSBA ordinance and any and all State of Connecticut traffic laws and regulations that pertain to operating a motor vehicle within the State of Connecticut. I assume financial responsibility for any personal injury or damage to property known to be caused by myself or other persons using the Golf Cart under this permit.(Required)

WHITE SAND BEACH ASSOCIATION WAIVER. HOLD HARMLESS AGREEMENT AND RELEASE OF LIABILITY In consideration for the privilege of operating my personal Golf Cart on WSBA roads the undersigned hereby agrees that: 1. I understand that there are inherent risks involved in operating a Golf Cart Type Vehicle on WSBA roadways and property, including the risk of serious physical injury or death and / FULLY ASSUME ALL RISKS ASSOCIATED WITH WHITE SAND BEACH ASSOCIATION, EVEN IF DUE TO THE NEGLIGENCE OF WHITE SAND BEACH ASSOCIATION AND THEIR AGENTS, SERVANTS OR EMPLOYEES, including but not limited to: accidents, incidents, injury and property damage, while acting in their official capacities for the White Sand Beach Association. I, for myself and for my heirs, assigns, successors, executors, administrators, and legal representatives, AGREE TO DEFEND. INDEMNIFY AND HOLD HARMLESS WHITE SAND BEACH ASSOCIATION AND THEIR AGENTS, SERVANTS OR EMPLOYEES from any and all claims, suits or demands by anyone arising from my use or operation of a Golf Cart Type Vehicle on WSBA roadways and property INCLUDING CLAIMS OF NEGLIGENCE ON THE PART OF WHITE SAND BEACH ASSOCIATION AND THEIR AGENTS, SERVANTS OR EMPLOYEES, while acting in their official capacities for the White Sand Beach Association. 2. I, for myself and for my heirs, assigns, successors, executors, administrators, and legal representatives, HEREBY RELEASE, AND AGREE THAT I WILL NOT SUE WHITE SAND BEACH ASSOCIATION AND THEIR AGENTS, SERVANTS OR EMPLOYEES for money damages for personal injury sustained by me while using or operating a Golf Cart Type Vehicle on WSBA roadways and property EVEN IF DUE TO THE NEGLIGENCE OF WHITE SAND BEACH ASSOCIATION AND THEIR AGENTS. SERVANTS OR EMPLOYEES, while acting in their official capacities for the White Sand Beach Association. THIS WAIVER INCLUDES USE OF OPERATION OF A GOLF CART TYPE VECICLE ON WHITE SAND BEACH ASSOCIATION ROADWAYS AND PROPERTY INCLUDING ALL CONTINUOUS FIELD AND BEACH SPACE. I HAVE READ THIS WAIVER. HOLD HARMLESS AGREEMENT AND RELEASE OF LIABILITY AND FULLY UNDERSTAND ITS TERMS. I FURTHER UNDERSTAND THAT BY SIGNING THIS AGREEMENT THAT I AM GIVING UP SUBSTANTIAL LEGAL RIGHTS. I HAVE NOT BEEN INDUCED TO SIGN THIS AGREEMENT BY ANY PROMISE OR REPRESENTATION. AND I SIGN IT VOLUNTARILY AND OF MY OWN FREE WILL.(Required)

Please upload your Certificate of Insurance Here(Required)

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