2021 Bike Burlington Member Form
Please complete and submit below.   Membership fees received in October - December paid applies to December 31, 2021.
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Email *
What type of membership is this: *
Select Membership  Option *
Adult 1 First Member Name *
Adult 1 Last Member Name *
Street Address *
City *
State *
Zip *
Adult 1 Member Age *
Adult 1 Member Cell Phone *
Adult 2 First Member Name
Adult 2 Last Member Name
Adult 2 Member Age
Adult 2 Member Email
Adult 2 Member Cell number
1st Child Under 18 Name
1st Child Under 18 Age
2nd Child Under 18 Name
2nd Child Under 18 Age
Additional Children, Age
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 *
Adult 1 Member Signature - Check the box below to AGREE NOT to sue Bike Burlington, Inc.                             *
Adult 2 Member Signature - Check the box below to AGREE NOT to sue Bike Burlington, Inc.                            
Parent or Guardian if under 18 Signature -  Check the box below to agree NOT to sue Bike Burlington, Inc.                            
Emergency Contact Information Name *
Emergency Contact Information Relationship *
Emergency Contact Cell Number *
Emergency Contact Other Number
Indicate your preference for payment.   Mail copy of the form with Check or Cash to Bike Burlington P.O. Box 1135 Burlington, Iowa 52601 *
Provide any additional comments
Membership Benefits:                                                                                                                                                                                *Access to the Bike Burlington Web Site (bikeburlington.org) 90% of our information comes from this site. After you have paid your club dues - go to the website and register. You will receive emails from the club on upcoming events and gain access to all pages on the website.                                                                                                   *Dinner rides on Wednesday evening 20 – 36 miles to a prearranged destination usually April –October Club meetings are the first Tuesday of every month with free soda/beer at Happy Joes.                                                                                                                                                                          *Club birthday party with free food and beverages.                                                                                      *Opportunity to participate in RAGBRAI and other organized rides.
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