Milepost Zero Bicycle Club                                2006

P.O. Box 1693

Waynesboro, VA  22980

Primary Member:  _________________________________

                        

Address: ________________________________________

City: _________________________________

State:__________________________________

Zip: __________________

Home Phone:  _______________________

Work Phone:  _______________________

Email Address:  _____________________________

2006 Membership Type:

___ Family/$15

___ Individual/$10

How do you prefer to get your MPZ Newsletter?

___ Snail Mail___E-Mail

For Family Memberships:

Spouse name: ___________________

Children  names:  ___________________________________-

Do you have an interest in, or would you like more information on the various MPZ Committees? 

(Check as many as apply):

___  Advocacy___  Tour de Valley Century

___  Ride Leader/Organizer___  Web Site 

___  Trail Maintenance___  Newsletter

___   Cookie Lady___  Fundraising

Cycling Interests (Check as many as apply):

___  Touring___  Mountain Biking

___  Health/Fitness___  Road Cycling

___  Fun/Leisure___  Tandem

___  Racing___  Cyclocross

Preferred Distance(s):Preferred Pace(s):

___  1-20 miles___  <10 mph

___  20-50 miles___  10-13 mph

___  50-75 miles___  14-17 mph

___  75+ miles___  17+ mph

Other Interests or Hobbies:

______________________________________

______________________________________

How did you find out about MPZ? _________________________________________________________

Please sign and send the following page.

WAIVER: In consideration of being permitted to participate in anyway in the Milepost Zero Bicycle Club rides and events, I, intending to be legally bound, release and discharge any and all claims for damages of death, personal injury, or property damage, which I may have, or which may hereafter accrue to me, as a result of my participation in Club rides and events. This waiver/release is intended to discharge in advance the Milepost Zero Bicycle Club, its officers, ride leaders, agents, and members from and against any and all liability arising out of or connected in anyway with my participation in Club rides and events, even though that liability may arise out of negligence or carelessness on the part of the Milepost Zero Bicycle Club, its officers, ride leaders, agents, and/or members.

I further understand that serious accidents occasionally do occur on bicycle events and that participants occasionally sustain mortal or serious personal injuries, and/or property damage, as a consequence. Knowing the risks, nevertheless, I hereby agree to assume those risks and to release and hold harmless the Milepost Zero Bicycle Club, its officers, ride leaders, agents, and members who (through negligence or carelessness) might otherwise be liable to me for damages and injuries. It is further understood and agreed that this waiver, release, and assumption of risk is binding on my estate, my heirs, and assigns.

I, also do hereby consent to permit emergency medical treatment in the event of injury or illness. I shall abide by traffic laws, practice courtesy and safe cycling, and wear an approved helmet at all times.

Signature of Primary Applicant:______________________________________  Date:______________________

For Family Memberships Only, please list all members:

1) Name: ____________________ Birthdate:    /  /____  (Spouse)

Signature:________________________________

2) Name: ____________________ Birthdate:    /   /____ (Child)

Signature:__________________________________

3) Name: ____________________ Birthdate:    /   /____ (Child)

Signature:__________________________________

4) Name: ____________________  Birthdate:    /   /__  (Child)

Signature:___________________________________

**If under 18, signature of Parent/Guardian is required here:

___________________________________________________