El Paso Bicycle Club P.O. Box 13040 El Paso, TX 79913

First Name____________________Initial________Last Name_____________________

Street____________________________________Apt. No.____________________

City_______________________________State__________________Zip_______________

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__________ Military: 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.

Signature______________________________D.O.B.________________Date_________________

Printed name of Parent or Guardian____________________________________________