First Name____________________Initial________Last Name_____________________
Home Phone__________________________Work Phone__________________________
Cell Phone________________________Email Address____________________________
I do / do not (circle one) wish to have my name, address, phone number and email address listed in a club membership directory which will be distributed only to club members.
Individual: $18.00 per year_________, $30.00 for two years__________
Family: $25.00 per year_________, $44.00 for two years__________ Active duty military and family members: First year free.
Enclosed is a check made payable to The El Paso Bicycle Club in the amount of $__________
Please enclose a membership application/liability release for each member of a family at a single address.
Liability Release: The undersigned (parent or guardian for persons under 18 years of age) represents and warrants that he/she possesses sufficient bicycling skills and competence to negotiate any and all road conditions that may be encountered on the proposed routes and that his/her bicycle is maintained in a safe operating condition. An ANSI or SNELL certified helmet is required on every ride. The undersigned acknowledges that he/she has read this release, understands its terms, and intends to be legally bound and agrees on behalf of the undersigned and his/her heirs, executors, administrators to release and hold harmless the El Paso Bicycle Club, its officers, members and or representatives for any and all blame or liability (including without limitation, liability for negligence or gross negligence) for any injury, damage, loss or inconvenience that may be experienced in connection with activities designed and conducted by the El Paso Bicycle Club.
Printed name of Parent or Guardian____________________________________________Signature_____________________________________Date_____________________