COBRAS Membership Application Form

Application Type:

TYPEVALUE

Contact Information:

First Name:
Last Name:
Street Address:
City:
State/Zip Code:
Home Phone:
Work Phone:
Mobile Phone:
Email Address:
Date of Birth: MM/DD/YYYY
USAC License:

Annual Membership Dues

Select Membership Type:

New Members Only

How did you hear about us?
If referred by an exiisting member, member name:

My Participation

Check all that apply

Race Marshal or other race event volunteer

Adopt a Highway

Publicity

Mentor a new member

Club Leadership Role

Ride Leader

Committee (such as membership, clothing, publicity, sponsorship)

Training

Social Event Planning

My special talents that I can contribute to the club are:

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				<div class="et_pb_code_inner"><h3>RELEASE</h3>
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<td><b>Note: This release form is a contract with legal consequences, and applies to all COBRAS activities and rides, not limited to racing and training events. Please read it carefully before signing.</b></td>
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<td>In consideration of the acceptance of my application for membership in COBRAS, I hereby freely agree to and make the following contractual representations and agreements.</td>
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I fully realize the dangers of participating in the sport of bicycle racing and fully assume the risks associated with such participation including, by way of example, and not limitation, the following: the dangers of collision with pedestrians, vehicles, other racers, and fixed or moving objects; the dangers arising from surface hazards, equipment failure, inadequate safety equipment, and weather conditions; and the possibility of serious physical and/or mental trauma or injury, including death, associated with athletic cycling competition.
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I hereby waive, release and discharge for myself, my heirs, executors, administrators, legal representatives, assigns and successors in interest (hereinafter collectively "successors") all rights and claims which I have or which may hereafter accrue to me against COBRAS, its sponsors, officers, directors and any activities organized or promoted by COBRAS; including travel to or from any such activities.
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I agree that it is my sole responsibility to prepare adequately for participation in races and club activities, and to maintain my bicycle and equipment in proper working order. I understand and agree that situations may arise during races, training rides and other COBRAS events which may be beyond the control of COBRAS and its members responsible for organizing such events and I must continually ride so as to endanger neither myself nor others. I will participate in all races and training rides wearing a helmet which satisfies the requirements of the USAC Racing Rules and that can protect against serious head injury, and assume all responsibility and liability for myself.
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I agree for myself and successors, that the above representations are contractually binding, and are not mere recitals, and that should I or my successors assert my claim in contravention of this agreement, I or my successors shall be liable for the expenses (including legal fees) incurred by the other party or parties in defending, unless the other party or parties are finally adjudged liable on such claim for willful and wanton negligence. This agreement may not be modified orally and a waiver of any provision shall not be construed as a modification of any other provision herein or as a consent to any other provision herein or as a consent to any subsequent waiver or modification.</div>
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				<div class="et_pb_code_inner"><input id="Execute" name="Execute" type="checkbox" value="y" /><b> I have carefully read and fully understand the contents and legal ramifications of this agreement as well as agreeing to abide by all COBRAS club rules. I understand this is a legally binding and enforceable contract and sign it of my own free will.</b> <b>Knowing and Voluntary Execution:</b></div>
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				<div class="et_pb_code_inner">By clicking “Authorize” you are signing and dating this Electronic Authorization, as of the date and local time that you click "authorize" and submit this agreement. And, you are representing that you have read, understand and agree to the matters set forth in this release. <input id="Authorize" class="et_pb_contact_submit" name="Authorize" type="submit" value="Authorize">

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