Please accept my membership in the Orrville Cycling Club. In consideration for membership in the Orrville Cycling Club, I have paid the club for this and further represent that I have no impediments to keep me from riding my bicycle in activities sponsored by the club. I will inspect my bicycle before any such activity to be sure it is in good and safe condition for the activity. I will observe all traffic laws. I understand that the Orrville Cycling Club, its officers, members and sponsors are not responsible for and are not insurers of my safety during any club activity. I thus release them and save them harmless from any and all liability arising from my having sustained any property damage or personal injury by reason of my negligence in participating, sponsoring, planning or arranging of any such activities.
____ Check if Renewal then fill out only name, signature and items to be changed
Name ______________________________E-Mail________________________
Address _________________________________________________________
Home Ph.___________Work Ph.___________Age_____Birth date___/___/___
Emergency Contact ________________________Phone___________
If you carry a cell phone or pager while riding, please enter number here___________
Family members
Name_____________Age_____Birth date___/___/___Signature_______________
Name_____________Age_____Birth date___/___/___Signature_______________
Name_____________Age_____Birth date___/___/___Signature_______________
Dues schedule: New Member:$25 Single, $35 Family; Renewal before March 15: $20 Single, $30 Family. Renewal after March 15: $25 Single, $35 Family. Make checks payable to Orrville Cycling Club. Return form with payment to Rich Corfman, 418 S. Walnut, Orrville, OH 44667.
Amount of Dues _______ Date Paid _______ Signature ____________________________