Permian Basin Bicycle Association
Club Membership Application
(Please type or print)
NEW MEMBER RENEWAL

__________________________________   ___________________________     _____________
Last Name   First Name Middle Name
__________________________________   _______________________  _______   __________
Address   City State Zip
________________________________  ______________________   ______________________
Daytime Phone                                                          Evening Phone                                   e-mail Address

_{Birthdate _______________________ I would prefer to receive my PBBA Newsletter by email}

List Additional Family Members          
_{____________________________________   _______    ___________  ___________    
Name                                                                     Sex             Birthday           Age                      
____________________________________   _______    ___________  ___________
Name                                                                     Sex             Birthday           Age
____________________________________   _______    ___________  ___________
Name                                                                     Sex             Birthday           Age}

_{Type of Membership (X One)}                 Individual   $25 a year              Family  $30 a year

I am interested in       Weekly Rides            Touring            Racing            Triathlons            ATB

Please read the following carefully—
Members to Release, Defend, Indemnify, and Hold Harmless the PBBA

 It is with the understanding that bicycle riding carries with it, under all conditions, certain dangers and risks to my safety that I read and sign the following:

In consideration of being admitted to membership in the Permian Basin Bicycle Association, the undersigned (for myself, my heirs, administrators and executors) agrees to release, defend, indemnify, and hold harmless the Permian Basin Bicycle Association and its officers, members, employees, sponsors, insurers, and attorneys (collectively “PBBA”), from any and all claims, suits, demands and causes of action of any kind or nature which arise from, relate to, or have any connection with the undersigned’s participation in any PBBA sponsored event. This agreement to release defend, indemnify and hold harmless includes, but is not limited to, all claims related to the PBBA’s and the undersigned’s own negligence.

This agreement shall be effective regardless of the theory of liability against the PBBA, including, but not limited to, the sole, joint, or concurrent negligence, gross negligence, intentional conduct of PBBA, liability based on any statute or government regulation, and strict liability; and as to all damages, including, but not limited to, compensatory damages, special damages, consequential damages, exemplary damages, and damages based on any statute or government regulation.

Signature________________________________________         Date_______________________

Signature________________________________________         Date_______________________
             (Parent or Guardian must sign for any minor children)

Please print and return with payment to:     Permian Basin Bicycle Association
4712 N. Midkiff Rd.
Midland, Texas 79705