Team Cobras
Membership Application

Applicant Information

First Name *

Last Name *

Gender *

Date of Birth *

Email *

Phone Number *

Address Line 1 * Address Line 2

City *

State *

Zip *

Emergency Contact

Contact First Name *

Contact Last Name *

Primary Phone *

Relationship *

Membership Details

What do you hope to benefit from by joining? * Referred By (if applicable)

Waiver of Liability

WAIVER AND RELEASE OF LIABILITY — READ BEFORE SIGNING

In consideration of being allowed to participate in any way in the 2020 Racing Inc. DBA Team Cobras program, its related events and activities, I, (name of participant), the undersigned, acknowledge, appreciate, and agree that:

1.The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,

2.I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, FOREVER DISCHARGE, INDEMNIFY, AND HOLD HARMLESS 2020 Racing Inc. DBA Team Cobras and USA Cycling, Inc., their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

3.I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and,

4.I willingly agree to comply with the stated and customary terms and conditions for participation. If, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the Company immediately; and,

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

I HAVE CAREFULLY READ THE PRECEDING AND UNDERSTAND ITS TERMS. I UNDERSTAND THAT I AM GIVING UP SUBSTANTIAL RIGHTS, INCLUDING MY RIGHT TO SUE RELEASEES AS SET FORTH ABOVE. I ACKNOWLEDGE THAT I AM SIGNING THIS AGREEMENT FREELY AND VOLUNTARILY. I INTEND MY ELECTRONIC OR HANDWRITTEN SIGNATURE TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT PERMITTED BY LAW.

Sign Below (Mouse or Touch) *

Confirmation

I have read and agree to the club rules and code of conduct. I understand that failure to follow club rules may result in termination from the club.

Date of Application

Dues Payment

Amount Due: $50.00

Card Number *

Expiration Date *

CVC *

Billing Country *

Billing Zip Code *