Suburbs Cycling Club

3 Lotus Road
Lotus River
7941
Fax: 086 675 3438
email: membership@suburbscyclingclub.co.za

Suburbs Cycling Club Membership Year: 2008/2009

New or Renewal? Membership Type F=Family; S=Single; J=U18

Title:(Mr, Mrs, Dr, etc) Initials: Gender:
Surname: First Name
Primary Member: Y/N No. of Family Members:
Postal Address: Postal Code:

Residential Address: Postal Code:

Date of Birth Age:

ID Number Email:
Telephone: Fax Number:
Cell: Emergency Number:
Blood Group

PPA Membership No: Super League No.

PPA Seeding No. Vets League No.
SACF No. Category

I/We agree to abide by the rules and regulations of the club as stated in the Suburbs Cycling Club Constitution
Subscription Payment Method
Club Kit
Total Received By:

Membership Renewal Date:

Memebership Fees:
Primary Family Member/Single: R150p.a. or R15pm
Additional Family Members/U18: R100p.a. or R10pm

Membership of Suburbs Cycling Club is renewable on an annual basis and runs from 1 January to 31 December each year. Family membership only applies to those of the
same family living at the same address. The subscription becomes payable on initial application. Subscription fees payable as follows - Full annual subscription payable if
joining before end June or half if joining July to December. (Note: there is a monthly payment option)

Cheques to be made payable to Suburbs Cycling Club and deposited into:

Account Name: Suburbs Cycling Club; Bank: ABSA; Branch Code: 632005; Account Number: 9210741140

WAIVER AND INDEMNITY

I hereby waive and abandon my right to institute any claim or action against Suburbs Cycling Club, its officials or members, in respect of any loss, damage, injury, or death
which I may sustain whilst participating in any cycling event or ride, whether formal or informal and whether as an official or competitor, which is organised by, run by, or
held under the auspices of Suburbs Cycling Club. I furthermore indemnify Suburbs Cycling Club against any loss which it may sustain as a result of any claim which may be
made against it by any third party arising out of loss, damage, or injury caused by me whilst participating as a competitor in any cycling event or fun ride, whether formal or
informal. The provisions of this waiver and indemnity shall be likewise binding upon my heirs, executors or administrators, as the case may be.

Signed: Date:

Guardian Signature (if a Minor): Date: