Date: ____________________

Please Check: New _____, Renewal _____, Individual ($10.00/yr) ________, Family ($13.00/yr) _____

For late Renewals (not first time members) postmarked after January 1st:

Individual ($13.00/yr) ________, Family ($16.00/yr) _____

Name _____________________________________________________ Date of Birth __________________________

Address __________________________________________________________________________________________

City/State/Zip ______________________________________________________________________________________

Occupation ______________________________________________________________________________

Home Phone _________________________________ Cell Phone _________________________________________

E-MAIL Address (NECCESSARY to mail Quick Release Newsletter) _______________________________________

Primary interests as a cyclist: ________________________________________________________________________

___________________________________________________________________________________________________

Spouse ________________________________________ Cell Phone ________________________________

Children ____________________________________________________________________________________

In consideration of my membership, I agree not to hold the Kingsport Bicycle Association, its officers or any of its members, liable for any injury, or damage which may result from participation in any event sponsored by the Kingsport Bicycle Association. I understand that as a bicyclist using public highways, I will be subject to, and agree to abide by, the same traffic laws as governs other vehicles. I understand that the Kingsport Bicycle Association does not accept responsibility for the safety of ride participants, that bicycling can be dangerous and that all participants in KBA activities assume responsibility for their own safety and the safety of their guests under the age of 18. All riders and their bikes are expected to be in condition to maintain an average pace of at least ten miles per hour. I agree to follow the KBA Riding Rules including being ready to Depart at the scheduled times and Riding as a Group by not leaving slower riders to fend for themselves.

Signature _____________________________________________________ Date _____________________________

Signature of Guardian if under 18 years of age ___________________________________________________________