Club Membership Registration Form

Wheelergy! Bike Club Membership Registration

Complete the form below to sign up for our membership service.
**Participant Information**
Full Name:

First NameLast Name
Age:
Grade Level:
Parent/Guardian Name:

First NameLast Name
Contact Phone Number:

Area CodePhone Number
Contact E-mail:
**Safety and Medical Information**
Medical Conditions/Allergies:
Emergency Contact Name:
Emergency Contact Phone:
**Agreement and Consent**
I, the undersigned parent/guardian, hereby give permission for my child,

_______________________________________________, to participate in Wheelergy! Bike Club. I understand that there will be biking activities, which may involve inherent risks. I confirm that my child is physically capable of particpating in these activities.

I also acknowledge and agree that the safety of the participants is a priority for Wheelergy! Bike Club. I have been informed that my child will receive first aid and road safety training as part of this program.

I understand that the first 20 participants will receive a free bike and helmet. I agree to abide by the program's rules and guidelines and ensure my child's attendance in the activities.
Parent/Guardian Signature and Date:*
**Registration Confirmation**
Upon submission of this form, you will receive a confirmation email with further details about Wheelergy! Bike Club. Please acknowledge you have read through the entirety of this Registration form by checking the box below.*

I have read, understood, and accepted the rules for membership.
**Contact Information**
For any inquiries or assistance, please contact us at wiseorg@outlook.com or 336-214-1645.
Once you submit your application, please look for a confirmation email.

Thank you!
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Wheelergy! Bike Club Membership Registration

**Participant Information**

**Safety and Medical Information**

**Agreement and Consent**

**Registration Confirmation**

**Contact Information**

Participant Information

Safety and Medical Information

Agreement and Consent

Registration Confirmation

Contact Information