Franklin Freewheelers Membership Application

b 2008 b

_____ Individual _____ New

_____ Family _____ Renewal

_____ One year membership fee of $15 enclosed (please make checks payable to Franklin Freewheelers, Inc. and mail to 5067 Franklin St., Rocky Mount, Va. 24151)

Name _________________________________ Spouse ____________________________

Birthdate ______________________________ Birthdate __________________________

Child __________________________________ Birthdate __________________________

Mailing Address ______________________________________________________________

City, State, ZIP _______________________________________________________________

Phone Nos. Home ______/____________ Work ______/____________

Cell ______/____________ e-mail ____________________________________

Emergency contact name ___________________________________ Phone______/____________

Note: Persons riding under the age of 18 must be accompanied by a responsible adult. This waiver statement must be signed by the participant, or, if under the age of 18, by the participant’s parent or guardian.

Waiver, Release and Assumption of Risk

In consideration of the Franklin Freewheelers, Inc. (FFI) accepting my membership application, I hereby waive, release and discharge the FFI and its officers, event leaders, volunteer helpers, support crew members, organizers, sponsors, and participants from all claims for personal injury, property damage or death resulting in my participation in FFI sponsored events. I realize there are certain dangers inherent in the sport of bicycling, and I assume these risks with full understanding that serious injuries, even death, may result from participation in FFI sponsored events. I intend this release to discharge the above named from any and all liability arising from or connected in any way with my participation in FFI sponsored events, even though that liability may result from negligence or carelessness of the above named. I certify that my bicycle is suitable for safe use, and that I am in good physical condition. I agree to wear an ANSI or SNELL approved helmet and to obey all traffic laws at all times during FFI sponsored events. I have read this waiver and release and fully understand its terms, and agree that it shall be binding on my heirs and assigns. I give my permission for such emergency medical treatment as may be required.

Signature ________________________________________ Date _________________