CSC Membership form 2010/2011

1. Your details

First Name

Last Name

Street Address

City

Postal Code

Email Address

Phone - home

Phone - work

Mobile Phone

2. Relevant medical conditions (eg asthma, bee allergy, heart condition)

3. Emergency Contact Details

First Name

Last Name

Relationship to you

Phone Number

Mobile Phone

4. Other family members who are included in your family membership

	Name	Medical conditions	Cellphone number
1
2
3
4
5
6
7
8

5. Due to my/our profession/training/experience, I/we can offer assistance in the following areas:

6. I/we have the following skills and/or interests that I/we would like to share with the club as a social or educational activity:

7. Which of the following email lists would you like to be added to:

	Trailbuilding on the Port Hills
	Trailbuilding at Living Springs

Club Rules

1. Every member must wear an approved hard shell safety helmet that is correctly fitted, and enclosed footwear, while riding at club events

2. Bicycles must be in good working order with functional front and rear brakes, handle bar ends must be plugged and have no sharp edges.

3. Riders must not use abusive or offensive language at events, behave in an anti-sporting manner, be disrespectful to other club members or ignore club rules.

I have read and undertand the club rules

Yes

8. Do you and all those in your family who wish to become members agree to the following condition of membership
Required Question

I hereby agree to abide by all club rules of the Christchurch Singletrack Club Inc. I attest that I am sufficiently fit to ride in general and at events safely and am aware of the risks involved. I hereby exempt the Club, Event Organisers, Landowners and Sponsors from any liability for damage that may occur to me or my property.

9. The 2010/2011 Membership fee is $15 per family + $5 per person MTBNZ levy. I am paying the following: Required Question

	Individual fee $15 + $5 levy ($20)
	Couple $15 + $10 levy ($25)
	Three person family $15 + $15 levy ($30)
	Four person family $15 + $20 levy ($35)
	Five person family $15 + $25 levy ($40)
	Six person family $15 + $30 levy ($45)
	Other size family - please indicate

10. Donations are gladly accepted. If you wish to make a donation, please indicate the amount here:

11. Please advise how you intend to pay your membership fee and/or donation Required Question

	Bank deposit - 03-1355-0659108-01 at SBS (use this if setting up new internet banking)
	Cheque - make payable to Christchurch Singletrack Club
	Bank deposit - 02-0820-0128675-083 at BNZ (if you have this already set up)
	Cash at a club event or meeting
	Not applicable

12. Do you require a receipt?

13. We would like to have a membership list on the club page. Please indicate which of the following best fits your circumstances Required Question

	First and Last name of adults displayed
	First and Last name of adults and children displayed
	First name only of adults displayed
	First name only of adults and children displayed
	No name displayed

14. How did you hear about us?

	Word of mouth
	Vorb posting
	Poster in shop/library
	Poster on track
	Web banner on car
	Internet search
	Newspaper article
	Magazine article
	Flyer at an event
	Other