LAST NAME, FIRST, MI:

BIRTHDATE:

ADDRESS:

CITY:

STATE:

ZIP:

HOME PHONE:

WORK PHONE:

CELL PHONE:

HOME EMAIL:

WORK EMAIL:

OTHER FAMILY MEMBERS AND AGES:

Is it ok to publish your name and phone number in the newsletter and club directory?

YES

NO

NEW MEMBER?

RENEWAL?

UPDATED INFORMATION ?

AREAS OF INTEREST ( circle)

ROAD

MOUNTAIN

TANDEM

TOURING

RACING

TRIATHLON

CAMPING

ADVOCACY

In consideration of the Highland Rimmers Bicycle Club granting me permission to ride in their events, I hereby waive all claims for damage or loss to my person and/or property which may be caused by any act, or failure to act, of the Highland Rimmers Bicycle Club, its officers or agents. I assume the risk of dangerous conditions on and about the route to be traveled and waive any and all specific notice of the existence of such conditions. I agree to wear an ANSI or SNELL approved helmet on all club rides. I also agree to obey all applicable vehicle laws and principles of safe bicycling.

SIGNATURE:

DATE:

SIGNATURE OF PARENT/GUARDIAN IF UNDER AGE 18:

DATE:

DUE ANNUALLY JANUARY 1