Name:

Date:

Address:

City:

State:

Zip:

Phone:

E-mail:

Type: (circle one)

• New
• Renewal

L.A.B. Member?

Age:

Individual Dues: $20.00

Family Dues: $25.00

If Family Membership, please print member names:

Membership Pledge:
I hereby agree to operate my bicycle in a manner that is safe to me and those around me, to observe all Rules of the Road, and conduct myself in a manner that will be complimentary to the sport. I release and waive all claims for negligence against the WHEELING WHEELMEN, its officers and members for all damages incurred at or associated with any WHEELING WHEELMEN activity for myself, my heirs and executors.

Signature: (Parent's signature if a minor)

_______________________________

Mail with payment to:
WHEELING WHEELMEN
P.O. Box 7304
Buffalo Grove, IL 60089-7304

Signatures of others on application:





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