Check one: ____ New Member ____ Renewal ____ Change of Address
Name: ________________________________________________
Address: _______________________________________________
City: ________________________ State: ____ Zip Code ________
Date of Birth: _________________ Phone: ___________________
Email Address: __________________________________________
***********************************************************************
Dues $20.00 per Family or Individual
Mail to: Polk Area Bicycling Assoc.
c/o Barbara Kelly
1416 Orangewood Drive
Lakeland, FL. 33813
*************************************************************************
By signing this form, I hereby for myself, my heirs, executors and administrators, release and forever discharge and hold harmless the Polk Area Bicycling Association, it's members, agents, servants, representatives, successors and assignees from all liability arising from or connected in any way with my participation in these events (or my minor child's participation in these events). I understand that there are risks inherent in participation in these bicycle rides, and I voluntarily assume such risk, knowing that my personal property may be damaged or destroyed and that I might suffer severe bodily injury or death. I recognize that it is my responsibility to ride in a safe and legal manner, and I agree to do so.
Signature: _________________________ Date: __/__/____
(If under 18 years of age or in the case of a guardian, signature of parent or guardian is required.)
Approved Bicycle Helmets are Required