Please fill in all applicable blank lines. Please print. Read and sign the Liability and Indemnification Agreement below. Please make checks payable to: KICKAPOO MOUNTAIN BIKE CLUB.

Emergency Contact Name & Phone:_______________________________________________________________

Membership Type (circle one):    Single ($10.00)    Family ($15.00)    Junior ($5.00)

Payment Method (circle one):    Check    PayPal

If a family membership, please indicate the names and ages of each member of the family to be included:

__________________________________________________________________________________________

Where did you learn about the KMBC?____________________________________________________________

I/We understand and agree that this application is subject to the policies, rules, regulations, and by-laws of the Kickapoo Mountain Bike Club, in force at this time or at any time in the future. I/We hereby agree to and will pay membership due in the amount determined by the Board of Directors of the Kickapoo Mountain Bike Club.

RELEASE OF ALL LIABILITY AND INDEMNIFICATION AGREEMENT
In consideration of the privilege of submitting this application, I/we do hereby for myself/ourselves and for my/our children under the age of twenty (20), my/our heirs, executors, administrators, and successors, assign, release and forever discharge the Kickapoo Mountain Bike Club, its officers, directors, and agents from any and all losses, claims, demands, actions, suits at law and in equity, judgments, and executions which I/we had, now have, or may in the future have, arising from or by reasons or any and all bodily or personal injuries whether known or unknown, death, and/or property damage resulting from, in connection with, or arising out of social events, social gatherings, social functions, bike and/or other trips, travel to and from bike and/or other activities, and any and all other sports activities, and any other activities of any kind or description in any way connected with the Kickapoo Mountain Bike Club.

I/We acknowledge that the sport of bicycling is a dangerous activity that can result in personal or bodily injury, included but not limited to or loss of personal property, including but not limited to, bicycling equipment. Furthermore, in consideration for the privilege of submitting this application, I/we on behalf of myself/ourselves individually, and on behalf of all family members under the age of twenty (20) LISTED ABOVE, and on behalf of my/our and their heirs, executors, administrators, or assigns, hereby agree to and will indemnify the Kickapoo Mountain Bike Club, its officers, directors, and its agents and hold them harmless from any suits, filing fees, costs of collection, and attorney fees.

I/We have read the foregoing APPLICATION AND RELEASE OF LIABILITY AND INDEMNIFICATION AGREEMENT and understand all of the terms thereof. I/We execute it voluntarily and with full knowledge of its significance.

ALL ABLE APPLICANTS MUST SIGN:

SIGNED:__________________________________________________________________________________

Date:_________________________________

SINGLE MEMBERSHIP is for any adult (18 years or older) wishing to join the Kickapoo Mountain Bike Club. A single membership may be converted to a family membership by filling out a new application and paying the $5.00 difference.

JUNIOR MEMBERSHIP is for minors under 18 whose parents are not members of the Kickapoo Mountain Bike Club.

Office Use Only: Date Received_____________ Number of Members_____________ Amount Enclosed_____________