SURNAME : …………………………………………………………………............…

FIRST NAME : …………………………………………………………………............…

POSTAL ADDRESS : ……………………………………………………………………............

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E-MAIL ADDRESS : ………………………………………………………..........…………….

TELEPHONE HOME : CODE : …...........……NO. : ……………………………………………

WORK : CODE : ………...........NO. : ……………………………………………

FAX : CODE : …...........……NO. : ……………………………………………

CELL : ………………………...........……………………………………………

DATE OF BIRTH : ………………….......……………………..GENDER : …...……………

BLOOD TYPE : ………….....ALLERGIES : ………........……………….……………….

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NEXT OF KIN : ……………………………………………………...........………………

CONTACT NUMBER : CODE : …….........…NO. : …..…………………………………………

CYCLING INTEREST : (Social, cross country or downhill racing )

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I hereby apply for membership of Durban Mountain Bike Club ("DMBC"). I undertake to adhere to the rules of the club as well as to the rules of KZNMBA, SAMBA and UCI. I understand that mountain biking can be dangerous and, on behalf of myself, my family and any personal representatives, I release and forever discharge DMBC, its members, sponsors, promoters and any other person or organisation involved with the club from all and any liability, claim or cost to myself or my property arising directly or indirectly out of my travelling to, attendance at or participation in any activity of the club. I irrevocably waive any claim which I may have against the club or its members arising from any cause whatsoever, including gross negligence, which may arise from my travelling, attendance or participation as aforesaid. I certify that the above information is correct and that I have read and understand the contents.

Date : …………………………....

Applicant’s Signature : …………..........................…………………………………………………………….