Clinic Registration Form - Advanced 1 1Registration2Personal Information3Cycling BC Licence4Payment Please read carefully I hereby release Kits Energy Training Inc. (Kits Energy) and any of the instructors or leaders working or volunteering with the company, from all liability in connection with the cycling clinic offered. This release has legal consequences and I have been advised to read it carefully before signing. I acknowledge that cycling is an inherently dangerous sport and I fully realize the dangers of participating in bike training rides. I fully assume the risks associated with participation including, by way of example and not limited to the dangers of colliding with pedestrians, cars, or other riders. I understand and agree that situations may arise during training rides and instruction, which are beyond the immediate control of Kits Energy and I will not hold any of these parties responsible for any injuries, losses, or other damages suffered by me. I take full responsibility for myself and agree to ride in a manner that will not endanger myself or others. I agree to follow the rules of the road at all times. I accept responsibility for the condition and safety of my equipment such as my bicycle and all of its components, wheels, and tires. I will wear an ANSI approved hardshell helmet on all training rides and while participating in coaching or instruction clinics. I agree that I am fit and healthy to participate in a cycling training program and do not have any injuries that will be made worse by participating. I understand that I can refuse participation in any activity at any point in time. I agree that I will not attend any workouts if I am feeling any symptoms of fever or sickness of any kind, and/or have not followed the most current quarantine requirements. This release may not be modified orally, and a waiver of any provision shall not be construed as a modification of any other provision.HiddenSignatureRegistrant's signature. By providing your signature, you are agreeing to the terms and conditions of the release statement.Consent(Required)By checking this box, you are consenting to the Terms and Conditions of the Release Statement above. I have read, understood, and agree. Date(Required)Today's date MM slash DD slash YYYY Name(Required) First Last Gender Female Male Nonbinary Birth Date(Required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email(Required) I would like to be notified about weekend group rides. I give consent for my email address to be made public to Kits Energy members. Yes No HiddenPublic EmailEmail to be used publicly for weekend group rides and events notification. Mobile Phone(Required)Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Emergency Contact Name(Required) First Last Emergency Contact Mobile Phone(Required)Additional InformationAllergies Medications Cycling Club Affiliations HiddenFor this season I am setting a goal to participate in the following cycling events:Check all that apply Ride Don't Hide in June Axel Merckx Fondo in July Valley Fondo in July Kits Energy Seymour climb in July Triple Crown in July Tour de Victoria in August Cypress Hill climb in August Ride to Conquer Cancer in August Whistler Fondo in September OTHER Please specify It is a requirement for all Kits Energy club members to hold a current Cycling BC Provincial Ride Membership or Race License. Do you already have a Cycling BC license or membership or will you purchase one through another club?(Required) Yes No Yes, I have a Cycling BC LicenceConfirm Cycling BC Membership Number(Required)I am fully aware and understand that before I can join or participate in the Kits Energy Cycling club, I must hold a current Cycling BC membership or license. Below is my Cycling BC number. No, I do not have a Cycling BC LicenceIn order to proceed with your registration, it is a requirement to own a minimum of a Provincial Ride membership which is purchased through the CCN website. Please click the button below. The Cycling BC website will open in a new tab where you can purchase your licence or membership." GET CYCLING LICENCE After you have finished your purchase, please copy and paste your membership number below to proceed with the Kits Energy Cycling club registration.Cycling BC Membership Number(Required)Please enter your membership number to confirm your licence or membership purchase. Kits Energy Cycling ClubCycling Clinics - RegistrationPlease note that all registrations are non-refundable and non-transferable. TEST on Wednesdays with Facundo ($495.00) Cycling Clinics - General RegistrationPlease note that all registrations are non-refundable and non-transferable. Advanced #1 on Wednesdays with Facundo ($495.00) Tax Price: $ 0.00 CAD Your TotalAll club registrations are non refundable and non transferrable. PLEASE NOTE. Once you hit REGISTER, you will leave the Kits Energy Registration page and be directed to PayPal and your registration will be complete. You will NOT return to this page. Upon making your payment in PayPal, you will receive an email, confirming your registration and providing more details for your season. Payment MethodPayPal CheckoutCredit Card MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name Untitled First Choice Second Choice Third Choice NameThis field is for validation purposes and should be left unchanged.