TRAILBLAZERS Tandem Cycling Club

TRAILBLAZERS Tandem Cycling Club

Stoker’s Registration Form

“We are a recreational cycling club with a twist. We give people who have limited or no vision the opportunity to cycle with sighted volunteers on our tandems (bicycle built for two).”

First & Last Name:

Street Address:

City/Province/Postal Code:

Home Phone Number:

Work or Cell Number ((optional)/please specify):

Home E-mail:

Work E-mail (optional):

Height: Feet:inches:

Weight (Pounds if possible):

AGE CATEGORY:Please complete – info needed for grants.

Delete & just keep your own age bracket.

16 – 19: 20-24: 25 - 64: 65 +:

Which shed would you prefer to cycle from?

CNIB Shed (1929 Bayview Ave.)

South Shed (Cavell & Royal York)

West Shed (Burnhamthorpe & The West Mall)

East Shed (Victoria Park Subway Station)

Complete if you are new.

Have you ridden a tandem before: Yes? No?

Cycling Preferences: Days__ Evenings:__Weekends Only:__

Can you volunteer for the club? Yes__ No__

Any special skills that you can share? (mechanic, writing…) Yes ___ No ___

How did you hear about the TRAILBLAZERS?

Any health issues that we need to know about that we should know for any future outings or events. (i.e.: Epilepsy, Diabetes, Asthma, Heart, etc.) No? Yes?

If so, please specify.

TRAILBLAZERS News Line: (416) 760-2700

Please mail cheque ($40) & both forms to:

Lynda Spinney, #611-340 Mill Rd. ETOBICOKE, ONM9C 1Y8

Today’s Date:

Administrative use only: Amount: $40 (enclosed)

Method: (Circle) _____Cash / Chq. #______

E-mail:

Website:

WAIVER AND RELEASE OF LIABILITY

I, ______, (Please print your name)

the undersigned, wishing to participate in the activities of TRAILBLAZERS Tandem Cycling Club, affirm to be in general good health, capable of the required effort, and hereby accept at my own personal risk any hazards that may occur. I hereby release TRAILBLAZERS Tandem Cycling Club, its directors, officers, servants, agents and trip organizers from any liability whatsoever for loss, damage or injury (including death) howsoever caused, which may result from my participation in the TRAILBLAZERS Tandem Cycling Club, and I declare that this release is binding upon me, my heirs, executors, administrators and assigns. I, the undersigned have read this release clause and agree that my participation in the activities of TRAILBLAZERFS Tandem Cycling Club is entirely at my own risk. I agree to wear an approved helmet on all rides.

Further, full permission is hereby given to use any photographs or movies of said person taken when cycling with the TRAILBLAZERS Tandem Cycling Club.

It is further understood and agreed that a Braille reference copy of this document is available; otherwise the print copy has been read to or by all members.

Signature:______Date: ______

Signature of Guardian: ______Date: ______

(If stoker is under 18 years of age)

Witness: ______Date: ______

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Original signatures Only: Please mail to:

Lynda Spinney, #611-340 Mill Rd. ETOBICOKE, ONM9C 1Y8