1/3 WESTWOOD VELO - BICYCLE CLUB Membership Application Release of Liability and Indemnification Agreement READ BEFORE SIGNING WESTWOOD VELO INC. (WV) is a not for profit organization - for bicycle enthusiasts of all ages. By riding, joining or involving yourself in WV, its training or racing events, or any other activities, you hereby agree to the terms and conditions noted below as a condition precedent to your involvement with the Club. This Agreement is given by the undersigned Applicant for the benefit of the WV, members, officers, trustees, sponsors, promoters, and volunteers (collectively "Releasees"). In consideration of being allowed to participate in any way in Westwood Velo, its related events and activities, I, ( ) , the undersigned, acknowledge, appreciate, and agree that: 1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and, 3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the Company immediately; and, 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND FOREVER DISCHARGE, INDEMNIFY INCLUDING AS TO ATTORNEYS FEES, PROMISE NOT TO SUE AND HOLD HARMLESS Westwood Velo Inc. their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity ("Releasees"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. This agreement may not be modified orally, and a waiver of any provision shall not be construed as a modification of any other provision herein or as consent to any other provision herein or as consent to any subsequent waiver or modification. I currently have no known physical or mental condition that would impair my capability to fully participate in cycling activities. I hereby understand that my membership in the WV is conditioned on my being a "Member in Good Standing".. To be considered a Member in Good standing with the WV, I will do the following: a. Sign, complete and return original copies of this Release of Liability and Indemnification; b. Submit all annual membership dues to WV as directed within a reasonable time frame; c. Volunteer and support at minimum one (1) WV race event during the Calendar year; d. Adhere to all USCF Athlete code of ethics e. If you are unable to support an event, you must speak to Alex Belgiovine (firstname.lastname@example.org) in advance to arrange for some other way to contribute to the Club or your membership shall be terminated. If your membership is terminated, no dues will be refunded.
2/3 I HAVE READ THIS RELEASE OF LIABILITY(PAGE1) AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. Signature: ______________________________________ Dated:__________________ Printed Last Name: ___________________________ First Name:_____________ MI ___ Date of Birth: ___/___/___ (if Under 18 please has Parent Guardian sign on Page 3) Address: ____________________________________ ____________________________________ __________________ State___ Zip _______ USCF License (Y/N) If Yes, License # _______________ Category __________ Norba License (Y/N) If Yes, License # _______________ Category __________ Phone: (____) ____-_______ E-Mail: _______________________________________ In Case of Emergency: Contact: ______________________ Relationship:_________________ Phone: (____) ____-_______ Attention: Westwood Velo Bicycle Club Members The following two items are conditions to your membership in WV: 1. Membership dues: Please note the dues for the 2012 season are $50. Late Payment - If paid after March 1 2012, WV may do either of a) Deny your membership in the club, and remove you from the USCF WV database b) Assess an additional $50 late fee; Please register via bikereg.com NO CHECKS WILL BE ACCEPTED 2. Mandatory Marshalling/Support of no less than one (1) Club Event. As part of the privilege of membership, each racing member is obliged to serve as marshal at one of the club events listed below. You must select a Preferred Event which you would like to support. Approximate dates are provided. The WVBC will thereafter advise the final support roster and which event to which you were assigned. Failure to attend or support the event to which you are assigned, without approval and exemption will result in your membership being terminated immediately. These events are the life blood of our Club and we believe we should all be able to provide one day to our club. If you are unable to attend any of these events, you must speak to Nick Alutin (email@example.com) in advance to arrange for some other way to contribute to the Club or your membership shall be terminated. If your membership is terminated, no dues will be refunded.. Silvermine/Longmeadow TT (approximately Early August) ___________ Cyclocross (approximately Early Oct )______________ Rochleigh Critieum (approximately Thursdays late May through late August )____________
3/3 RELEASE BY PARENT OR GUARDIAN I, as parent or guardian of the Applicant, represent to the Releases that the facts herein concerning my child or ward are true. I give my permission for my child or ward to participate in any club activities during the period of membership in the WV, and further, in consideration of such membership, agree, individually and on behalf of my child or ward, to the terms of the above Agreement. Signature of Parent or Guardian____________________________________ Dated:__________________ ***SUBMITTING THE WAIVER AND DUES***** Membership Dues: Please register via bikereg.com using the following link: http://www.bikereg.com/events/ConfList.asp?EventID=7585. All applicants must sign the release and indemnification agreement and Register via Bikereg.com. Return the completed release to
Nick Alutin c/o Westwood Cycle
182 3rd Ave Westwood NJ 07675
For more info Please call Nick 201-803-2463 or
182 Third Ave
Westwood NJ 07675
Store Hours: Mon 10-8 Tue-Wed 10-7 Thurs-Fri 10-8 Sat 10-6 Sun 11-3
*Prices and avalibility subject to change without notice.