Mid-Valley Bicycle Club Membership / Renewal Form

(please use the online process at join.mvbc.com if you are able to do so) Membership Type  NEW Member; or  RENEW I (We) want to join the Mid-Valley Bicycle Club. Enclosed are annual dues as indicated below. FAMILY Membership  $25.00 Full-Year

INDIVIDUAL Membership  $20.00 Full-Year

STUDENT Membership  $10.00 Full-Year

Primary Contact/Applicant – Must be an Adult (18yrs or Older) Name: ____________________________________

Phone: ______________________________________________

Address: ___________________________________________________________________________________________ (Street)

(City)

(State)

(Zip)

Email: ____________________________________ Alternate Contact/Applicant – Must be an Adult (18yrs or Older) for FAMILY Memberships ONLY Name: ____________________________________

Phone: ______________________________________________

Email: ____________________________________ Distribution Lists Please check below, if you wish to be added to monitored/screened email lists (see email-lists.mvbc.com for details): •  [email protected] •  [email protected] FAMILY Membership Participant Names Adult (18yrs or Older) Participant(s): ____________________________________________________________________ Minor (Less than 18yrs) Participant(s):___________________________________________________________________ Signatures In consideration of my application, I hereby, for myself, my executors and administrators, waive and release any and all rights and claims for damages I may have against the Mid-Valley Bicycle Club, its officers, and members, prior to, during, and after my membership or association with the club or any event. I agree to accept all rules and regulations of the club. Adult Participant Signature(s): _________________________________________________________________________ Adult Parent or Guardian Signature(s) for Minors: _________________________________________________________ Date: ___________________________________ Send with Check to: Mid-Valley Bicycle Club, P.O. Box 1373, Corvallis OR 97339-1373 In addition to completion of the above MVBC membership/renewal form, please complete the attached “Release and Waiver of Liability” form from the League of American Wheelmen dba League of American Bicyclists (LAB). This form is required annually by our insurance carrier. Complete a separate form for each adult (age 18 or over) in the household. In addition, if there are minor children in the household participating in MVBC activities, complete the Minor Release section of the Release and Waiver of Liability form for each minor in the household. MVBC Registration & Liability Waiver Forms, 1/22/2015

MVBC Registration & Liability Waiver Forms, 1/22/2015