Membership Application Form – Cannonballs Cycling Team

This information is required to enter you into our district database if your application is accepted.

Name

First

Last

Date of Birth (mm/dd/yyyy)

Email

Mobile Phone

Home Phone

How do you prefer to be contacted? (Select all that apply)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Where do you work?

What is your role there?

Rider Height (Feet)

Rider Weight (lbs)

This section will help us learn a bit more about your interest in Rotary.

How did you hear about us? (Select all that apply)

Profile Name

Strava Profile Name

Are you currently affiliated with any cycling group, team, or club?

If yes, please list the name of the group, team, or club

What is you riding experience?

Briefly share your riding experience

of (please do

Please share your Rotary preferences to help us ensure the best fit.

Why are you interested in joining Rotary? (Select all that apply)

Agreement

I understand that if my application is accepted, I will be expected to participate regularly and pay annual dues.

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