Students Full Name

Students Date of Birth

Students Address

Contact Phone Number

Contact Email Address

Emergency Contact Name

Emergency Contact Number

I confirm that I am a member of Cycling Ireland.

Declaration, Indemnity, Waiver and Agreement.
I wish to apply to apply for membership of Willow Wheelers Cycling Club (which together with the club’s committee, officers, members, representatives and agents, Willow Park Junior School, Willow Park School (First Year) and Blackrock College is referred to as the Club) and I hereby undertake to abide by all rules of the Club, to know and adhere to the rules of the road and abide by all the decisions of the Club and its committee. I declare that I am medically and physically fit and able to participate in cycling activities. I agree to follow any rules set by the Club or by activity organisers in connection with any Willow Wheelers cycling activities. In particular, I acknowledge that safety is the main priority and it is compulsory to wear a helmet at all times during Willow Wheelers cycling activities. I understand and accept that because of the possibility of mishaps and accidents occurring, there exists a possibility of serious physical injury and damage to property occurring and I therefore hereby irrevocably and unconditionally declare and agree that I exclude the Club from and I therefore hereby indemnify the Club from liability for any loss, injury damage to persons or property or otherwise howsoever and whatsoever including that which I may sustain, suffer or cause as a result of my participation in any activities of or in connection with or organised or administered or run by the Club whether in or outside Ireland.

Parental Consent.
I/we being the parent/parents/legal guardian of the applicant, having read and understood the above declaration, indemnity, waiver and agreement, agree to being bound and to the applicant being bound by its clauses, on the applicant’s behalf and give my/our consent for the applicant to participate in the activities of the Club subject to the terms of this Application and to the rules of the Club as amended from time to time.

Signed by the Parent or Legal Guardian

Total Amount: €35.00

Student Membership Application

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