A new membership form must be signed each year of membership renewal

PRIVACY: You are guaranteed that any personal details collected will be kept private, in accordance with the Privacy Act 1993.

If applying for a family membership, please fill out one form each person eligible for membership as set out below.

DETAILS:

NAME:         .............................................................................................................................DOB:................................................

Address: .....................................................................................................................................................................................

Phone:.......................................................MOB: ............................................EMAIL:.................................................................

EMERGENCY CONTACT: ............................................................  (relationship to you).......................................PH:...........................

MEDICAL CONDITIONS (OPTIONAL)...............................................................................................................BLOOD TYPE:....................................

Are you a ......Mountain Biker      Y/N                Road Rider     Y/N                Both     Y/N

CLUB FEES: PER YEAR I.E 1/11/2014 TO 31/10/2015

INDIVIDUAL:        $65.00

FAMILY:                $110.00                Max 2 adults and 2 children under age 17 that share same address

JUNIOR:                $40.00                Under the age of 17

ASSOCIATE:        $20.00                Associate DOC member – belongs to another affiliated club and/or for race license purposes

All fees are for DOC membership only and do not include any coaching fees, BikeNZ or MTBNZ race or membership fees.

Department of Cycling Bank Account: ASB 12-3066-0283262-00 – Pls put your name in “particulars” for internet banking

DATE PAID....................................... CHQ/CASH/DD?........................................$...........................................................................

CONDITIONS of membership of the Department of Cycling:

SAFETY

 While the club will take every reasonable precaution to ensure the safety of the participants on bike rides and events, all participants undertake bike rides and events entirely at their own risk and neither the club nor ride leader nor any other participant will accept responsibility for accidents or damage to person or property, whether caused by negligence or otherwise. All participants shall obey all laws and regulations regarding use of public roads, including keeping to the left side of the road and not endangering personal safety or property of themselves or anyone else

GENERAL RULES

Membership of the club and participation in any ride or event is dependent on members agreeing to all of the conditions herein and signing of this waiver. · NZ Safety Approved cycle helmets must be worn at all times whilst riding. · Stay as far left of the centre line at all times as is practicable. Never cross the centre line · Indicate clearly your intentions of movement · Do not ride more than two abreast and ride in single file whilst passing other vehicles (whether moving or parked) · Be considerate to all other road users · Be willing to stop and assist other riders if and when needed. · Keep your cycle and equipment maintained to ensure the safety of yourself and others

 MINIMUM AGE – ROAD RIDERS ONLY

The minimum age to become a member is Intermediate School age. Intermediate school aged children must be riding with adult supervision arranged by their parent/guardian. Any person 15 years and under must be accompanied by a parent/guardian/caregiver member 18 years and over. However if a younger child is proven to the satisfaction of the Club President or Club Captain to be a competent and safe cyclist, they may become a member, but subject to adult supervision at all times, arranged by their parent/guardian

WAIVER

I have read, understand and agree to the conditions of the Department of Cycling.  On behalf of myself, my heirs, assigns and personal relatives,  I waive  release and forever discharge the Club or its contractors, ride leaders, committee members, sponsors, other organisations, officials and volunteer helpers or other participants  whatsoever from any and all liability, claim, loss, cost or expense arising from or attributable in any legal way to the action or the omission or act of any such person or organisation or execution of any racing or sporting event, including travel to and from such event in which I might participate as a rider, team member or spectator.

To the best of my knowledge I have no physical condition which would interfere with my ability to participate in or attend any such event, or which would endanger my health. I Consent to the information supplied on this form being incorporated into the Club’s register and for it to be available to Club Members to contact each other on Club related matters.  I also consent for photos showing myself taken during cycling events to be displayed on the clubs website or facebook page.  I may request for a photo to be removed by contacting chairman@deptofcycling.com.

Signature........................................................................................................................... Date....................................................................

(to be signed by parent/guardian if applicable under 16 years of age).