Clinic Registration Form - Intermediate 2 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. Reset signature Signature locked. Reset to sign again Consent to Terms and Conditions(Required)By checking this box, I am consenting to the Terms and Conditions of the Release Form 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)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email(Required) Please add my email address to the Intermediate 2 distribution list to help with communication and organize group rides. Yes No HiddenPublic EmailPublic email you are willing to share. 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 would like to set 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 Triple Crown in July Kits Energy Seymour Climb in July GS Cypress Challenge in August Tour de Victoria 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 racing license. Do you already have a Cycling BC license or membership?(Required) Yes No Yes, I have a Cycling BC LicenceCycling BC Membership Number(Required)Please enter your membership number to confirm your licence or membership purchase. 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 ProgramsHiddenCycling ClinicsRegister before Jan 1st and receive discounted pricing. Please note that all registrations are non-refundable and non-transferable. Int #2 on Tuesdays with Elaine ($495.00) Cycling Clinics - General RegistrationPlease note that all registrations are non-refundable and non-transferable. Int #2 on Thursdays with Kristina($495) Tax Price: $ 0.00 CAD Your TotalPlease note that all registrations are non-transferable and non-refundable. PLEASE NOTE. Once you click the PayPal Payment button, you will leave the Kits Energy Registration page and be directed to PayPal. Upon making your payment, you will receive an email, confirming your registration and providing more details for your season.Payment MethodPayPal Checkout MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name PhoneThis field is for validation purposes and should be left unchanged.