| Personal
Information |
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| First name: |
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Last name: |
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| Address: |
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City/Town: |
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| Postal Code: |
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Telephone: |
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| Email: |
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Cell/Mobile: |
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| Confirm email: |
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Emergency Telephone: |
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| Date: |
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Emergency Contact: |
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Please select one of the following
options regarding the member directory: |
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NO, I do not want my details, except for my Name, published
in the Highwood Cycling Club Directory |
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YES, I want the following details
published in the Highwood Cycling Club Directory (check
any/all you wish) |
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Full Address
City only
Email |
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Cell/Mobile phone
Home phone |
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NOTE: To protect this info, the
membership directory will be distributed ONLY TO PAID MEMBERS
via email. The directory is also intended to help members
be aware of others in the club and a channel for communication. |
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| Membership
(select one only with additional family names if needed) |
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Individual Membership ($50.00) |
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Family Membership ($90.00, 2 Adults same family) |
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Other Family Member name |
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Family Membership ($105.00, 2 Adults plus 2 children under
18) |
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Other Adult Family Member |
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Family Member children names |
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Junior Member ($25.00, under 18 years of age) |
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| How
I Like to Ride |
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Road (Low intensity recreational) |
Mountain (Difficult, challenging, extreme) |
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Road (High intensity, training) |
Mountain (Moderate skill and difficulty) |
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Racing |
Mountain (Easy, rolling, non technical) |
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Touring (Long distance, often a few days) |
Fitness & Exercise |
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| Tell us about
your cycling (goals, desires, ProTour wins) |
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| Comments or Questions |
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