2023 Membership Licence Application form

YesNo
UCI Code:*
Full Name*

First NameLast Name
MaleFemale
Birth Date*

DayMonthYear
Nationality*
Contact Information

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E-mail
example@example.com
Phone Number*

Area CodePhone Number
Pickup Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Upload a proper recent photo of yourself*

Passport size photo (Good quality please)
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Upload proof of ID*

(ID or birth certificate) Passport size photo
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CLASS

Only competitive, recreational and commuter riders are covered by accident insurance. Select recreational or commuter rider if you are a technical official who also rides.
Choose Class:
CATEGORY:

In order to register as a junior/master or any other age guided category, please calculate your age as at December 31 of the year of registration. (Eg. If you are born 2002, your age for 2020 is 18, regardless of your exact date of birth.)
Choose Category
DISCIPLINE:

Select any or all of the disciplines you participate in.
Choose Discipline:
YesNo
Guardian's Information:

Guardian's signature required if the applicant is under 18 years of age
Guardian's Name*

First NameLast Name
Guardian's Signature*

Clear
Emergency Contact:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

Contact Information