Name:   __________________________________  Home Phone: ____________Work Phone: ____________

Home Address:  _______________________________      
 
                         ____________________________

Email                ______________________________

In consideration of, and as an inducement to, the CARBONDALE BICYCLE CLUB permitting me to participate in their
rides, I hereby certify and represent the following:

1.  I realize bicycling is a dangerous sport, which can occasionally result in harm or death to its participants.

2.  Furthermore I understand the rides will be carried out primarily on public roads without special traffic control.

3.  I am fully aware of any and all danger inherent to bicycling and willingly assume all risk and responsibilities of
participation in this ride.

4.  In signing this release for myself, or for the named entrant (when the entrant is under 18 years old), I understand the
intent of this release and agree to waive to the fullest extent permitted by law any and all claims I may have against the
CARBONDALE BICYCLE CLUB, its members, officers, directors, committees, and/or agents arising out of or in any
way connected with such participation.

5.  I furthermore certify that the entrant and his or her equipment are physically prepared for this event, and the entrant will
exercise due caution, obey all traffic laws and wear a helmet at all while bicycling.

I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND ITS CONTENTS.  I AM
AWARE THAT THIS IS A RELEASE OF LIABILITY AND WAIVER OF CLAIMS AND SIGN IT OF
MY OWN FREE WILL.

DATE:  _________    Signature ___________________________________________

            Parent or Guardian________________________________________

Send Completed membership form and release, along with the membership fee of $10.00 to:

    Diann Bauer, 515 N. Helen, Carbondale, 62901, IL  62901

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