Membership Application

Circus City Cyclists

Membership Application/Release

Name ___________________________________________ Date___________________

Address_________________________________________ Phone___________________

City__________________________ State____ Zip_______ Email ___________________

Occupation____________________ Age________ Dues: Single $15____ Family $20____

Names of Family Members:__________________________________________________

Please Mark One - New Member ____ Membership Renewal ____

In consideration of the acceptance of this application for membership in the Circus City Cyclists Bicycle Club,

I hereby release, discharge and agree to hold free and harmless, the sponsors, organizers, and other members,

single and/or collectively, from any and all liability for any injury, misadventure, harm, loss, or inconvenience to

property or person suffered by me as a result of my taking part in Circus City Cyclists Bicycle Club rides and

activities. I also hereby consent to and permit emergency medical treatment in the event of injury or illness.
In signing this release for myself and family, I acknowledge that I understand its intent and agree to operate in

a cautious and prudent manner. I shall abide by traffic laws and regulations and practice courtesy and safety

in cycling.

THIS IS A RELEASE - READ BEFORE SIGNING

Signatures:_________________________________________________________________________________

Print, Complete, and Mail to: Circus City Cyclists, 154 N. Grant St., Peru, IN 46970 (765) 473-3848