GATEWAY REGION

AMA CHARTER 32338

A MEMBERSHIP COMPOSED OF CYCLING ENTHUSIASTS WHO HAVE REACHED THE AGE OF 40 “XL+” OR MORE. (MEMBERSHIP RUNS JANUARY 1 TO DECEMBER 31)

(Check one) New______ Date:____________________

Renewal______

(Print or Type)

NAME:______________________________________SPOUSE:_______________________

ADDRESS:_____________________________________________PHONE:_(_____)_______________

CITY:___________________________STATE_________________ZIP:___________

E-MAIL:____________________

BIRTHDAYS:______________-____-_______AND______________-____-_______

AMA MEMBERSHIP NO:_________________________AND_________________________

Suggestions for our club: _____________________________________________________________________________________

___________________________________________________________________________________________________________

“MEMBER GETTER”:______________________________CARD #:___________

DONATION: $______________(Enclosed) The Club suggests a minimum of: 1 YEAR $ 20.00 COUPLE 15.00 SINGLE

PLEASE::: MUST SIGN!!!!!

I understand that the Retreads cannot assume responsibility for any aspect of my safety and that if I participate in any event, I do so Voluntarily on my own assessment of my ability, any course, and all facility conditions, assuming all risk; and I release and hold the Retreads Harmless for any injury or loss to my person, property which might result there from. I understand that this means that I agree not to sue the Retreads for any injury resulting to myself or my property at any such event.

Signature________________________________Spouse_______________________________

Make checks and mail to: GATEWAY REGION RETREADS

2662 PHIL’S LANE

LAKE CHARLES, LA. 70611

(337) 855-7487

FAX (337) 855-1737

FOR REGION USE ONLY: Card numbers:_____________&_____________

Date mailed:__________________________

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