Membership Application Form

Membership Application - For Applicants Who are Members of Cycling Ireland

To apply for membership please complete all questions.
Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

E-mail
Mobile Number

Area Code Phone Number
Garda Registration Number
Station (If Serving or Reserve Member)
Current Garda Status
Are You a Member of IPA (Ireland)
How Did You Hear About Us?
Have You Cycling Ireland Insurance
Cycling Ireland Insurance Details i.e: Policy Number, Dates etc
Please Outline Any Health Issues
Cycling Experience
IPACC Membership Fee

IPACC Membership Fee € 25.00 EUR
IPA Cycling Club Membership Runs from January to January
IPA Cycling Club is affiliated with Cycling Ireland. By joining the Club you will agree to take out a separate licence with Cycling Ireland. Details including Personal Insurance Cover are available on www.cyclingireland.ie.

Declaration: I wish to become a member of the IPA Cycling Club and I agree as a member of the Club that I must adhere to the Club Constitution & Club Rules (available on request), the Rules of Cycling Ireland and The Rules of the Road. At all times I am solely responsible for my own safety both on and off the bike and at no time shall IPA Cycling Club or its officers be held liable or accountable for my actions, at any organised and non-organised Club Event or Cycling Ireland event. I agree that no liability in respect of injury, loss or damage whatsoever shall attach to the Club, its Members or Officers in the event of such injury, loss or damage howsoever arising during the course of any such Club or non-Club event. I accept that my membership application is subject to the approval by the Management Committee.
Signature
Date

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Membership Application - For Applicants Who are Members of Cycling Ireland