PCC Member Registration | Prairie Cycle Club ..

After completing this form (*'d fields required), clicking on the Submit button below directs you to Paypal for payment (be prepared for a 5 to 15 second delay). Once at Paypal, to pay by credit card, click on the link near the bottom right that says either "Don't have a Paypal account" or "Pay with a debit or credit card".

Report any difficulties to webmaster@prairiecycleclub.org

Name*

First

Last

Address*

Street Address City State Zip Code

Email*

Phone*

Area Code

Number

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New or renewal membership?*

New

Renewal

Membership Type:*

$20 Individual

$25 Household (multiple persons at same address)

$15 Student OR dues paying individual belonging to CCB, <br> Bike Project or Wild Card Cycling

$5 Upgrade from individual to household membership

$0.35 DON'T CHOOSE. FOR TESTING ONLY

Household Membership Additional Name

First

Last

Household Membership Additional Email (optional)

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Waiver and Release (Required)*

Waiver and Release (Acknowledgement Required)

In joining the Prairie Cycle Club, I/we acknowledge that bicycling in and of itself can be dangerous, and hereby release and waive all claims against the Prairie Cycle Club (PCC), PCC members, PCC officers and directors, and successors and assignees, for damages resulting in injury either to myself or to my equipment, during any and all PCC-sponsored events. Helmets are strongly recommended for all PCC- sponsored bicycling activities and for all bicyclists.

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If payment will be made with a credit card belonging to a person other than that named at the top of this form, please indicate this person's name below. This enables us to match the completed membership form (sent to us from this website), with the payment notification (sent to us from Paypal with only the credit card holder's name).

Payee (if not named above)

First

Last