logo Membership Form

 Name:  __________________________

Address:  ______________________________________________

Phone:  _______________________

Family Members:  _____________________________________________

Email Address:  ________________________________________

Principle Ride Class:  Unsure __ AA __ A__ BB __ B__ CC __ C __ D __Tandem __

(See Website for Class specifications)

*Annual Membership Dues: $10 individual or $15 for complete family.  $ ____

Non-Paying Member ___ (Please add me to the email & Newsletter list)

How did you hear about us:  ___________________________________

Are you interested in organizing or leading rides?  _________________

 *Paid members will have discounts on club jerseys, any other HCBC merchandise and given a membership card to carry with them on rides, etc.  Dues are for each calendar year beginning in January.  (No prorating of yearly dues) Please submit this form with your membership fee and mail to:  HCBC, C/O Andy Lash, 10523 Henry Rd , Henry , VA   24102 .  Renewals need not resubmit this form unless you have updated contact info.

Assumption of Risk/Waiver of Claim                                         Date:  _______________

I, ____________________, (please print) wish to participate in recreational activities offered by the HCBC.  I understand that the above-mentioned program involves activity that can be both strenuous and physically demanding and could result in my being physically injured.    I assume all risk of any physical injury or other loss that I might sustain as the result of participating in this activity.  I further assume any risk during travel to and from the area where the activity will take place.

I understand the importance of following all rules and regulations relating to this activity including obeying traffic regulations and the ride leaders’ requirements for the organized rides/activities.  I have and will wear my helmet while operating my bicycle at all times!

I have read this waiver and release and discharge the HCBC, its officers, ride leaders and other volunteers from all claims for injury, property damage or death from participating in any HCBC sponsored event.  I further certify that I’m in good physical condition and my bike and helmet are safe to operate and properly worn.

Signature ________________________________