Membership Application
(Please Print)
| Name | Birthdate |
| Address | Age |
| City | Occupation (Optional) |
| Zip Code | Cell Phone (Optional) |
| Phone: Home ( ) | FAX |
| Phone: Work ( ) | E-mail Address |
In consideration of SCOR Cardiac Cyclist Club, Inc. Permission to participate in Saturday/Sunday club rides as well as special events, (Solvang Century, Solvang Prelude, ¼ & ½ Century, San Diego Century), I hereby waive and release any and all rights and claims for damages which I may have against SCOR Cardiac Cyclist Club, Inc, the locations of where the events take place, as well as any other person or company connected with these events, their heirs, executors, successors, administrators and assigns for any and all injuries which I may suffer for taking part in these rides or as a result of these. I attest I am physically fit enough to participate in these rides. Further, any and all pictures, video and/or media release by the club as it sees fit. I agree to wear an approved helmet on all club rides and encourage others to do the same. Persons under age must have this waiver signed by a parent or guardian. |
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| Signature | Date |
| Parent or Guardian | Date |
Annual
dues run from January 1 thru December 31 of the same year |
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| (562) 690-9693 | SCOR Office E-mail |
| Ride Schedule | |
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