Name : _____________________________ Birth Date: ____/____/____ Adult    Minor under 18

Address: ___________________________ City : ____________________ ST:_____ Zip:______________

Home Phone: ____/____________ Work Phone: ____/____________ E-Mail: ________________________
Data Base Options:           I'm New I'm Renewing; BCI #: ________
·A Membership Roster is available online to members, listing name, address, email & home phone.
Do you want to be listed in the roster? NO; DO NOT list me in the roster. (Omit me)
·The BCI occaisionaly provides our mailing list to cycling related various groups, businesses & ride promoters.
Do you want to receive this mail? NO; DO NOT give my address to others.
·The Club newsletters are available online.       Mail me hard copies: I can't/won't access PDF files on line.
In Case Of Emergency - Contact: (Name/Number)_____________________________________________
If injured or unconscious, it is important to carry ID & emergency contact info. Is there someone we should call?

How did you hear about the club?________________________________________________________
Give the name of the Member who referred you to the Club, their membership will be extended as a Thank You...

What kind of bike(s) do you ride/own?
Road     Touring    Comfort (Commuter/Hybrid)    ATB (All-Terrain/Mountain)
Tandem  Unique (Recumbant / Hand driven / 3 wheeled / Big Wheeler / Other:______________ )

How far do you currently enjoy riding? (in miles)
SHORT (20 or less)   MEDIUM (25-30)   LONG (over 40)   CENTURIES (100+miles)

ACCIDENT WAIVER AND RELEASE OF LIABILITY - REQUIRED FOR MEMBERSHIP READ CAREFULLY: THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS
I acknowledge that bicycling is an extreme test of a person's physical and mental limits and carries with it the potential for death, serious injury and property loss. The risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of athletes, equipment, vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, event officials, and event monitors, and/or producers of the event, and lack of hydration. These risks are not only inherent to athletics, but are also present for volunteers. I hereby assume all of the risks of participating &/or volunteering in this activity. I realize that liability may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained or controlled by them or because of their possible liability without fault. I certify that I am physically fit, have sufficiently trained for participation in the event and have not been advised otherwise by a qualified medical person. I acknowledge that this Accident Waiver and Release of Liability (AWRL) form will be used by the event holders, sponsors and organizers, in which I may participate and that it will govern my actions and responsibilities at said events. In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows: (A) Waive, Release and Discharge from any and all liability for my death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter accrue to me or my traveling to and from this activity, THE FOLLOWING ENTITIES OR PERSONS: The Bicycle Club of Irvine, their directors, officers, employees, volunteers, representatives, and agents, the event holders, event sponsors, event directors, event volunteers; (B) Indemnify and Hold Harmless the entities or persons mentioned in this paragraph from any and all liabilities or claims made by other individuals or entities as a result of any of my actions during this activity. I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident and or illness during this event. I understand that at this event or related activities, I may be photographed. I agree to allow my photo, video or film likeness to be used for any legitimate purpose by the event holders, producers, sponsors, organizers and or assigns. This AWRL shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I hereby certify that I have read this document; and, I understand it's content. PARENT GUARDIAN WAIVER FOR MINORS (Under 18 years old) The undersigned parent & natural or legal guardian does hereby represent that he/she is, in fact, acting in such capacity and agrees to save and hold harmless and indemnify each and all of the parties referred to above from all liability, loss, cost, claim or damage whatsoever which may be imposed upon said parties because of any defect in or lack of such capacity to so act and release said parties on behalf of the minor and the parents or legal guardian.
_________________________	_____________________________	____________
Signature of Participant	Signature of Parent/Guardian if under 18	Date Signed/Joined
Please send this form (with your dues made payable to the Bicycle Club of Irvine) to: Data Management Services · 405 E Wilson Ave · Orange CA 92867-4832 e-form Revised 06/15/04     Link back to BikeIrvine.org      Link to Current Dues

     Set fonts small & print this page or open Membership Form in PDF