California Deaf Wheelers

Membership Application

    Cycling enthusiasts, friends or sponsors may become members by paying ten dollars per year. Membership entitles you to be member of both USDCA and CDW and a subscriber to the Breakaway and eBreakaway newsletter.

    Please fill out and submit the form. Upon receipt of the due payment, we will validate your membership immediately. Please write "CDW" on the Memo line and a check of $10 payable to Ethan Bernstein at:

      Ethan Bernstein, CDW Treasurer
      39103 Delano Court
      Fremont, California 94538

    First & Last Name: 

    Address: 

    City:   State:   Zip: 

    Visual Phone Number: 

    E-mail Address:   (Required to fill)

    Please check your current membership  

    (a) Renewal  New  Renewal after several years

    (b) Competition  Recreation  Coach  Sponsor  Friend  Organization

    (c) Which of the following information fits you:

    Stop Here and submit your membership application at the bottom. Thank you

    For those who are interested in race and/or be on the team, please fill the blanks below:

    Are you a racing cyclist?   Yes  No

    What bike type?     Mounatin  Road  Both

    Male   Female

    Weight:    Height:    Birthdate:  e.g. 00-00-0000

    School:   

    College: 

    Occupation: 

    United States Cycling Federation:   Yes  No    

    Class:  Junior  Senior  Master 

    Category:  5  4  3  2  1 

    Cycling Club: 

    NORBA:   Yes  No

    Cross Country Category: 

    Mountain Bike Club: 

    Please comment if any question about this application or others given below: