NORTHBROOK BICYCLE CLUB
MEMBERSHIP APPLICATION 2005

I hereby make application to join the Northbrook Bicycle Club. I understand that it is a racing club. All Members are
encourages to participate in competitive events as either a USCF licensed or citizen racer. No rider will be permitted to
ride USCF races as a member of the Northbrook Bicycle Club without paying the required membership dues and
without purchasing a club jersey. The Northbrook Bicycle Club reserves the right to reject any membership application.
Any reference in this application to USCF shall include USA Cycling and NORBA.

As a member of the Northbrook Bicycle Club, I agree that, if I apply for a USCF racing license, I will register with them
as a member of the Northbrook Bicycle Club. I understand that the Club does not restrict me from riding in non-USCF
sanctioned events. I further agree that I shall conduct myself at all times with dignity, good sportsmanship, and follow
the rules of conduct as promulgated from time to time by the USCF.

Before participating in any event at the Northbrook Velodrome, I will sign the required release, pay any required fees
and insurance surcharges.

NAME:

ADDRESS:
Street

City State Zip

TELEPHONE:
Home Telephone Number

Business Phone Number

EMAIL ADDRESS:

BIRTH DATE:

RIDING AGE (Age as of 12/31/05):

SOCIAL SECURITY #: USCF LICENSE NUMBER
USCF CATEGORY (1-5)
NORBA CATEGORY

WE HEREBY RELEASE THE NORTHBROOK PARK DISTRICT AND THE NORTHBROOK BICYCLE
CLUB, INC., THEIR OFFICERS, DIRECTORS, REPRESENTATIVES AND ASSIGNS FROM ANY
LIABILITY IN CONNECTION WITH OUR MEMBERSHIP AND/OR IN CONNECTION WITH OUR
PARTICIPATION IN ANY CYCLING EVENT, TRAINING RIDE OR EVENT, OR CYCLING PROGRAM.

SIGNATURE: DATE:
(Parent or Guardians Signature if Applicant is Under 18)

FOR RIDERS UNDER 18:
NAME OF PARENT:

SS NUMBER:
ADDRESS:

SIGNATURE:

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DUES/INSURANCE (Circle Amounts Being Paid): Make Checks Payable to NORTHBROOK BICYCLE CLUB

2005 NEW ADULT (Includes Jersey): $80.00 Jersey Size ( ) XS, S, M, L, XL, XXL
2005 RENEWAL (If you have a Jersey): $30.00 Extra Jersey: $42.00
2005 NEW USCF JUNIOR (Under Age 12) $72.00
Racing One Piece: $95.00
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Northbrook Bicycle Club, Inc., 1111 Waukegan Rd., Northbrook, IL 60062, Attention: Club Membership
Affiliated with the Northbrook Park District and member United States Cycling Federation, Inc.
Call (847) 291-2974 x 646 for location and other details.

RACING TEAM OFFICIAL SPONSORS:
GARNER CYCLERY ,SUNSET FOODS, THE LANDMARK INN, GREAT HARVEST BREAD CO., ATHLETICO,
CLIF BAR, RUDY PROJECT, SPECIALIZED BICYCLES, AND NORTHBROOK PARK DISTRICT.