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| Date: | Membership type (Single or Family): | |
| Name: | ||
| Address: | ||
| City, State, Zip | ||
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| Email Address: | ||
| Family Membership Names: | ||
| In consideration of accepting my dues, I, My heirs and my executers release the Mid-America Bicycle Club and any of its members, officers or co-sponsors from any liability arising from illness, injuries and damages I may suffer as a result of my participtaion if club activities. If a family membership, all of the family have been appraised of this condition and agree to its terms. | ||
| Signature: | Date: | |
| Parent or Guardian Signature: | ||
| *** ANSI Approved Helmets Are Mandatory On All Rides *** | ||
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