Franklin Freewheelers Membership Application

b  2016  b

                        _____  Individual                                           _____  New

                        _____  Family                                                 _____  Renewal

 

_____  One year membership fee of $15 enclosed (please make checks payable to Franklin Freewheelers, Inc. and mail to 5067 Franklin St., Rocky Mount, Va. 24151)

 

Name      _________________________________      Spouse ____________________________

 

Birthdate  ______________________________            Birthdate  __________________________

 

Child __________________________________            Birthdate  __________________________

 

Child __________________________________            Birthdate  __________________________

 

Child __________________________________            Birthdate  __________________________

 

Child __________________________________            Birthdate  __________________________

 

Mailing Address  ______________________________________________________________

 

City, State, ZIP  _______________________________________________________________

 

Phone Nos.  Home  ______/____________                      Work  ______/____________

 

                    Cell     ______/____________      e-mail  ____________________________________

 

Emergency contact name  ___________________________________ Phone______/____________

 

Emergency contact name  ___________________________________ Phone______/____________

 

Note:   Persons riding under the age of 18 must be accompanied by a responsible adult.  This waiver statement must be signed by the participant, or, if under the age of 18, by the participantís parent or guardian.

 

Waiver, Release and Assumption of Risk

                In consideration of the Franklin Freewheelers, Inc. (FFI) accepting my membership application, I hereby waive, release and discharge the FFI and its officers, event leaders, volunteer helpers, support crew members, organizers, sponsors, and participants from all claims for personal injury, property damage or death resulting in my participation in FFI sponsored events.  I realize there are certain dangers inherent in the sport of bicycling, and I assume these risks with full understanding that serious injuries, even death, may result from participation in FFI sponsored events.  I intend this release to discharge the above named from any and all liability arising from or connected in any way with my participation in FFI sponsored events, even though that liability may result from negligence or carelessness of the above named.  I certify that my bicycle is suitable for safe use, and that I am in good physical condition.  I agree to wear an ANSI or SNELL approved helmet and to obey all traffic laws at all times during FFI sponsored events.  I have read this waiver and release and fully understand its terms, and agree that it shall be binding on my heirs and assigns.  I give my permission for such emergency medical treatment as may be required.

 

 

Signature  ________________________________________            Date  _________________