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NI Spin Membership 2012

NI Spin Membership 2012

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Published by Steven Schurtz

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Published by: Steven Schurtz on Oct 01, 2011
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10/01/2011

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Membership Application
P.O. Box 1281Mason City, Iowa 50402
North Iowa Touring ClubNorth Iowa SpinMason City Multisports
 Name: _______________________________ Address _________________________________ City: _________________________________ State ______________ Zip Code _____________ Email: _______________________________________ 
(This should be an email you check frequently)
Home Phone: ___________________________ Office Phone: ___________________________ Cell Phone: _________________________ Emergency contact: __________________________ Parent/Spouse/Significant Other: ______________________________ Health Insurance Provider: _________________________ Policy No. _____________________ Age in 2012
(Race Age)
: ____________________ Date of Birth: __________________________ Occupation: _____________________________ Education: _____________________________ Road Category: _____________ Licensing Authority: ______________ License No. _________ Mountain Category: _____________________________________________________________ Triathlon Category: _____________________________________________________________ 
MEDICAL:
Describe any medical conditions that may effect your training, racing, or anyinformation medical providers may need when providing care to you: _____________________________________________________________________________  _  _____________________________________________________________________________  _ Circle areas of Interest:Cross Country Skiing * Downhill Skiing * Canoeing * Cycling * WalkingRunning * Teach others * Help Organize * Hiking * Camping * Sailing North Iowa Touring ClubSingleFamily15.0020.00 North Iowa Spin15.00Mason City MultiSports15.00Total
By signing this membership application, you acknowledge you understand that training,participating and competing in all sporting events are potentially dangerous activities. Youagree to hold the North Iowa Touring Club, North Iowa Spin, and Mason CityMultiSports, their members, officers sponsors, and all other persons and organizationsassociated with North Iowa Touring Club, North Iowa Spin, and Mason City MultiSportsharmless should you be injured or killed. Further, by signing this contract you agree tobind yourself, your heirs and all personal representatives. The time period of this contractshall commence on the date signed through December 31, 2012.
Signature: _______________________________________ Date: ________________________ 

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