2019 Bike Burlington Member Form
Please complete and submit below.
Email address *
What type of membership is this: *
Select Membership Option *
Pay membership fee by *
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Adult 1 First Member Name *
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Adult 1 Last Member Name *
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Adult 1 Member Age *
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Adult 1 Member Cell Phone *
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Adult 2 First Member Name
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Adult 2 Last Member Name
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Adult 2 Member Age
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Adult 2 Member Email
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Adult 2 Member Cell number
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1st Child Under 18 Name
Your answer
1st Child Under 18 Age
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2nd Child Under 18 Name
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2nd Child Under 18 Age
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Additional Children, Age
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Street Address *
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City *
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State *
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Zip *
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Convenant not to sue: The undersigned, for and in consideration of the privilege of participating in events and activities organized and sponsored by Bike Burlington, Inc. Hereby convenants and agrees not to sue Bike Burlington, Inc. Its officers or agents for damages which may be incurred by the undersigned arising out of the negligence of Bike Burlington, Inc. its officers or agents.
Please Note: Bike Burlington does not carry insurance to replace or repair its member's bikes, in case of theft or damage of any case. We recommend each member check with their individual insurance agent to see if their bike(s) are covered, and if not to look into additional coverage.
Date *
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Adult 1 Member Signature *
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Adult 2 Member Signature
Parent or Guardian if under 18 Signature
Emergency Contact Information Name *
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Emergency Contact Information Relationship *
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Emergency Contact Cell Number *
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Emergency Contact Other Number
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Provide any additional comments
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