2015/16 Gravity Canterbury Club Membership Application

To take part in our club events you must be a member of Gravity Canterbury or another MTBNZ-affiliated club. Please fill it in and
bring to your first club event for the season. (A form/fee is not required from members of other clubs who race in our events but
you need to verify your out-of-town club membership and sign an on-the-day consent to abide by our race rules.)

Full name
Home address
Cell phone

Home

Email address (please print neatly!)

Date of Birth

(under 18 riders at time of registering must get a

parent/caregiver to fill in the consent section below)

Consent required

Please read and sign the following. A parent/caregiver must sign on behalf of riders aged under 18 years.

I agree and understand the following:

1. I participate in events organised by the club entirely at own risk. I have considered and understood the nature of such events. I am
sufficiently responsible and be responsible for my own safety.
2. I know that events may take place on public roads and assume responsibility for my own safety in relation to other traffic and observe
the laws relating to road traffic.
3. I agree that while participating in any event I do so without any liability whatsoever on the part of the club, committee, event
organiser, or any club or organisation affiliated thereto or its officials or members, in respect of any injury, loss or damage suffered by
me due to my own actions.
4. I confirm that I have no disability or medical condition, physical or mental, which could affect my ability to ride safely. I understand
that I must notify the secretary of the club at once if I become subject to a disability or medical condition, physical or mental, which
could affect my ability to ride safely.
5. I consent to any emergency treatment necessary during the course of an event. I authorise the event organiser(s) to sign on my
behalf any consent required by the hospital authorities, in the case where a surgical operation or serum injection may be deemed
necessary, providing that the delay involved to obtain my signature may be considered in the opinion of a doctor or surgeon
concerned, likely to endanger my health or safety.
6. I acknowledge that my bicycle and personal belongings are transported at my own risk and it is my responsibility to ensure that my
bicycle is secured before transport commences.

Signed (Rider OR Parent/Guardian) _______________________________________________________ Date: _____/______/______

Paid
Cash
Cheque
Membership fee for the season
$20 per rider

Please volunteer to help

Our races can only take place with an enormous amount of volunteer help. We ask ALL members to volunteer themselves, or
supply a volunteer, for at least one event each season. No volunteers = no events.
Please contact me/my supporter about helping with:

Marshalling
Van driving (25+)
Race timing Race base helper
Other please specify (e.g. prizes, BBQ cook, food for volunteers, sponsorship)
Volunteers name:___________________________________________Phone: _____________________________________

TURN OVER THE PAGE AND ANSWER THE MEDICAL INFO SECTION, PLEASE.
BRING THIS FORM AND YOUR $20 TO THE FIRST RACE YOU ENTER FOR THE 2015/16 SEASON.

MEDICAL INFORMATION

Your full name _______________________________________________

This information is required so that timely and appropriate medical care can be provided in the event of an accident.
The information will remain confidential, only Gravity and race organisers, ambulance and hospital staff will have
access to it.
Tick below if you have any of these medical conditions listed and provide any details that first aid or emergency
services need to know about.

Diabetes... If so, are you on insulin?

Other conditions that first aid/emergency services need to know about?

Heart disease
Asthma or other respiratory problems
Problems with your bones or joints, including metalware such as plates or screws
Recently fractured bones
Problems with blood clotting
Epilepsy or other problems of the nervous system
Head injury, loss of consciousness or concussion. Please give dates.
Are you on any medication? Please specify.
Do you have allergies to any medications including skin cleansers such as iodine?
Is there any reason why you should not be given a blood transfusion in the event of this being recommended
by medical staff?

Please provide details if you ticked any of the above. Thank you.