Northeast Bicycle Club

		Amount
	Single/Primary Membership ($30.00) Additional Family Member ($20.00) Junior-17 and under ($10.00)	$
	Buy a "Wicked Fast" 2008 Time Trial Season Pass ($50)	$
	Support Mass Bike's advocacy programs (voluntary) $2 suggested, more is better	$
	Total	$

First Name
Last Name
Gender	Choose Male Female
Date of Birth (MM/DD/YYYY)
Street and Number
City
State
Zip Code
Racing Category	Cat 1 Cat 2 Cat 3 Cat 4 Cat 5 Citizen
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

Please Note: NEBC maintains an on-line directory of members, consisting of name, racing category, and town of residence. Email and phone number are also available to other club members via a password. If you do not wish to have your name published in this Directory, check the box below.
I do not want my name placed in NEBC's Membership Directory.

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.
I have read the liability waiver and agree to its terms and conditions.
Name of parent or guardian (if applicant is under 18):