Club Membership Registration Form

Club Membership Registration

Complete the form below to sign up for our membership service.
Name*

First NameLast Name
E-mail*
Phone Number:

Area CodePhone Number
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date:

MonthDayYear
Gender

FemaleMalePrefer not to answer
USAC #
Discipline (check all that apply)

RoadCyclocrossMountainEnduroDownhillGravel
Interests

Group RidesSocial EventsRacingVolunteering / Supporter RoleClinicsTraining Rides
Social Media
Instagram
Twitter
Facebook
Membership Rules
1)      Represent the Foundation, supporters, sponsors, and affiliates in a positive manner.

2)      Update your race affiliation with USAC and local affiliates to Amy D Foundation

3)      Social media posts using the hashtag #RideLikeAmyD and tagging sponsors and supporters.

4)      Give back to the community.

5)      Have fun.
I have read, understood, and accepted the rules for membership.

My Products

Membership Fee (includes a Grassroots jersey)$150.00

Size

Enter coupon

Total $0.00

Submission button will take you to checkout at PayPal. We will contact you after we have received your submission and your payment.

Thank you!
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Club Membership Registration