Membership Form

Name_____________________________________________

(if address is the same as last year just write SAME)

Address___________________________________________

City_________________________ State______ Zip________

Phone (_________)__________________________________

Email ___________________________________________________________

Occupation______________________________________________________

Other Family members registering ______________________ ______________________

Type of Membership
__Individual ($20) / ___Family ($25) / ___Student ($15)

Would you prefer to receive the newsletter from the WRCC web site or by USPS Mail?
_____ WRCC Web Site _____ USPS Mail

Type of Cycling
Commuter___/Touring____/Racing____/Mountain____

May we publish your name in our directory? __Yes / __No

Are you a member of Indiana Bicycle Coalition? ___Yes/ ___No

IN CONSIDERATION of being permitted to participate in any way in WABASH RIVER CYCLE CLUB ("Club") sponsored Bicycling Activities ("Activity") I for myself, my personal representatives, assigns, heirs, and next of kin:

1. ACKNOWLEDGE, agree and represent that I understand the nature of Bicycling Activities and that I am qualified to participate in such Activity. I further acknowledge that the Activity will be conduct over public roads and facilities open to the public during the activity and upon which the hazards of traveling are to be expected. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the Activity.

2. FULLY UNDERSTAND that: (a) BICYCLING ACTIVITIES INVOLVE RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS AND DEATH ("RISKS"); (B) these Risks and dangers may be caused by my own actions, or inactions, the actions or inactions of others participating in the Activity, the condition in which the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time, and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation in the Activity.

3. HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE , AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS the Club, their administrators, directors, agents and employees, other participants, any sponsors, advertisers and if applicable, owners and leasers of premises on which the Activity take place, (each considered one of the "RELEASEES" HEREIN) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the "releasees" or other wise, including negligent rescue operations.

I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID, THE BALANCE NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.

Signature of rider
___________________________________________________Date:_____________

Signature of parent or guardian if registrant is under 18 years of age
_________________________________________

Make checks payable to Wabash River Cycle Club and mail to:

WABASH RIVER CYCLE CLUB
P.O. Box 1243
LAFAYETTE, IN 47902-1243