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Black Bear Cycling
2011
Membership Application

New Member Renewal

Name: Jersey Size: (see size chart)

Address:

Town, State: ZipCode +4:

Daytime Phone: Evening Phone:

Cell Phone: E-mail address:

Emergency Contact and info:

Interests (check all that apply):
Touring/Recreational Racing Advocacy

First Year Dues: $60 for those 18 and over, $40 for those under 18.
I agree to all club rules and regulations. I also agree to wear an approved helmet on
all club rides, ride in a safe manner, and to obey all motor vehicle and bicycling laws.
I have also read and signed the Black Bear Cycling Club Release and agree to its terms.
 
Signature of Applicant: __________________________ Date: _______________
Signature of Parent or Guardian if applicant is under 18 years of age:
 
_______________________________________ Date________________
Print, sign form and release and make check out to: Black Bear Cycling
and snail mail to:
Black Bear Cycling
15 Larch Ave
Sussex, NJ 07461


RELEASE OF LIABILITY- READ BEFORE SIGNING
In consideration of being allowed to participate in any way in the Black Bear Cycling
program, its related events and activities, I, _____________________________________,
the undersigned, acknowledge, appreciate, and agree that:
  1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,
  2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERS, AND ASSUME FULL RESPONSIBILITY FOR MY PARTICIPATION; and,
  3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the representatives of Black Bear Cycling immediately; and,
  4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS BLACK BEAR CYCLING, THEIR OFFICERS, OFFICIALS, AGENTS, AND/OR EMPLOYEES, OTHER PARTICIPANTS, SPONSORING AGENCIES, SPONSORS, ADVERTISERS, AND, IF APPLICABLE, OWNERS AND LESSORS OF PREMISES USED FOR THE ACTIVITY (RELEASEES), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK
AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I
HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT
FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
_____________________________ | ______ | _____________
Participant's Signature | Age | Date Signed
FOR PARENTS/GUARDIANS OF PATICIPANTS OF MINORITY AGE
This is to certify that I, as parent/guardian with legal responsibility for this
participant, do consent and agree to his/her release as provided above of all
Releasees, and for myself, my child and our heirs, assigns, and next of kin. I release
and agree to indemnify and hold harmless the Releasees from any and all liabilities
incident to my minor child's involvement or participation in these programs as
provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE
RELEASEES, to the fullest extent permitted by law.
___________________________ | _________________________ | _________
Parent/Guardian's Signature | Printed Name | Date Signed