• Member
  • Discipline
  • Emergency
  • Medical
  • Final

Applicant's Contact Details

First Name

Last Name


Contact Number

Date of Birth

ID Number

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Residential Address

Street Number & Road Name


Post Code



List Your Discipline Criteria

Primary Discipline

Indicate Discipline


CSA ID (Lic No)

ROAG ID (Lic No)

Skill & Fitness Based On Universal (UCI / IMBA) Ratings

Skill Level Rating

Fitness Level Rating

Annual Registration Fee Plan

Select Plan Option

Emergency Contact Details

Primary Emergency Contact Name

Primary Emergency Contact Number

Secondary Emergency Contact Name

Secondary Emergency Contact Number

Alternative Emergency Contact Name

Alternative Emergency Contact Name

Medical Aid Detail

Medical Aid Name

Medical Aid Plan

Medical Aid Number

Medical Aid Primary Member Name

Medications | Allergies | Blood Type

Please list any allergies

Please list any medication you may be on or in case of emergencies

Blood Type

Club Affiliation Prospects

Please provide name of KPCC member who can vouch for you.

Terms & Conditions

I understand: 1. That my online application form must be submitted online and will be reviewed by the committee for acceptance. 2. That the Executive committee has the right to refuse any application for membership without assigning any reasons for such refusal. 3. That the membership fee shall accompany my application upon committee agreement and confirmation of acceptance is communicated to myself. If my application is not accepted, such fee shall be returned to me. 4. Upon acceptance, I shall get myself familiar with the club’s constitution which can be found on the website www.kingsparkcycling.co.za. I hereby indemnify the KINGS PARK CYCLING CLUB and hold it harmless against all claims for damages to property and all claims arising from death of, or injury to, any person whomsoever, or damage to equipment to vehicles whether partaking or otherwise involved in, in any activity or in any cycling event organised or authorised by the Kings Park Cycling Club. Persons selecting the below check box of this online indemnity form as guardian of a minor hereby consent to such minor being bound by the foregoing & further indemnify any parties, if any, to which such a minor is not capable of waiving his/her rights as stipulated above.

I agree to the Terms and Conditions

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