Hawkeye Bicycle Association

Last Name ______________________   First Name __________________________  Middle I ____   

Street Address __________________________________________________________________

City _________________________ State _______________ Zip Code _____________________  

Home Phone (_____)___________    Work Phone (_____)__________   Cell Phone (_____)________

Age ___        Email________________________________________________________

Were you an HBA member last year? _________

Emergency Information (Person to contact in case of an emergency)

1.  Last Name __________________ First Name_________________________________ 

     Relationship _________________ Phone # (___)___________

2.  Last Name ___________________ First Name ________________________________

     Relationship ________     Phone # (___)___________

WAIVER:  I do hereby for myself, heirs, executors, and administrators, waive any and all claims for damages and causes of action of every nature which may hereafter accrue to me against the Hawkeye Bicycle Association and sponsoring agencies during participation in association events or during travel to and from any association events.

Signature of Applicant _______________________________________________  Date ___________________

Name of Accompanying Adult (if applicant is under 18 years of age)

Last Name __________________ First Name_________________________________ 

Relationship _________________ Phone # (___)___________

Signature of Parent or Guardian (if applicant is under 18 years of age)