Amount

$

Buy a "Wicked Fast" 2012 Time Trial Season Pass ($50) $

Support Mass Bike's advocacy programs
(voluntary - $2 suggested, more is better) $

Total $

First Name:

Last Name:

Gender:

Date of Birth: (MM/DD/YYYY)

Street and Number:

City:

State:

Zip Code:

Racing Category:

USCF/NORBA License Number: (if unlicensed, enter "none")

Club Named on your Racing License: (if not racing for NEBC)

Occupation:

Employer:

Phone Number: (please include area code)

Alternate Phone Number:

E-mail Address:

Liability Waiver
Please read our liability waiver, and note your consent below. If you are under 18, this form MUST be completed by
a parent or guardian, and the name of that person noted below.

Email List(s)
You will be automatically added to the General Club Email List, this list is the primary means of communication used
to announce club news, events, and other pertinent information (such as clothing orders). You may unsubscribe
at any time by following links at the bottom of every email sent to the list. Each racing team also maintains their own
email alias, to be added/removed from those, please contact the appropriate team captain.

I have read the liability waiver and agree to its terms and conditions.

Name of parent or guardian (if applicant is under 18):

		Amount
		$
	Buy a "Wicked Fast" 2012 Time Trial Season Pass ($50)	$
	Support Mass Bike's advocacy programs (voluntary - $2 suggested, more is better)	$
	Total	$

First Name:
Last Name:
Gender:
Date of Birth:	(MM/DD/YYYY)
Street and Number:
City:
State:
Zip Code:
Racing Category:
USCF/NORBA License Number:	(if unlicensed, enter "none")
Club Named on your Racing License:	(if not racing for NEBC)
Occupation:
Employer:
Phone Number:	(please include area code)
Alternate Phone Number:
E-mail Address:

2012 NEBC Membership Application