League Cycling Instructor Candidate Seminar
2024
Information for Seminar Site Facilitators
Please thoroughly read this document to understand the role and responsibilities of the Site Facilitator of
an LCI seminar. This document is the basis for the Memorandum of Understanding (MOU) located at the
end of the document. A signed MOU must be returned to the League of American Bicyclists in order to
organize a LCI seminar in your community. Send any questions to education@bikeleague.org.
TOPIC (Click on a topic to find in the document) PAGE
LCI Candidate Pre-Requisites…………………………………………………………………………….1
Seminar Objectives…………………………………………………………………….…………………...1
Timeline…………………………………………………………………………………….…….………....3
Site Facilitator Summary Checklist…………………………………………………………..……………...7
Seminar Invoicing………………………………………………………………………………..………….7
Cancellation Policy………………………………………………………………………..………………...7
Seminar Scholarship Application Template……………………………………………………...……….8
Attachment A, MOU (to be returned)........................................................................................................10
Attachment B, Draft Agenda……………………………………………………………………………....11
Attachment C, Sample Scholarship application…………………………………………………………...13
Attachment D, Agreement of payment………………………..…………………………………………..18
_____________________________________________________________________________________
LCI Candidate Pre-Requisites
Certification as a League Cycling Instructor (LCI) requires a candidate to first be a student of the
Smart Cycling curriculum by taking the Smart Cycling Complete Class, which includes:
Classroom Component: The Smart Cycling Basic, Intermediate and Advanced material
instructed by a current LCI in the classroom or may be completed online at
learn.bikeleague.org. The written exam must be successfully completed with a score of 85%
or higher prior to taking the LCI seminar.
On-Bike Component: Bike handling skills, avoidance maneuvers, and road ride instructed by
a current LCI. The on-bike exam must be successfully completed with a score of 85% or
higher prior to taking the LCI seminar.
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Objectives of Your Seminar (pass on to all applicants)
The seminar will be at least 23 hours in length and will focus on teaching cycling safety. Candidates
should already be competent and experienced cyclists. The seminar is to learn how to effectively
teach safe cycling.The LCI seminar is arranged by a Site Facilitator and conducted by a designated
League Smart Cycling Coach.
At the end of the seminar, candidates will be able to:
Demonstrate competence in principles and skills of the Smart Cycling program, including vehicular
bicycling, understanding the importance of bike infrastructure, different types of bicycle equipment,
bike maintenance, and specialized bike-handling maneuvers.
Understand basic teaching principles and techniques as they apply to both children and adults, and
demonstrate them through practice teaching during the seminar.
Be familiar with specific Smart Cycling materials and existing courses and how riders will benefit from
Smart Cycling classes.
Develop an understanding of the “Need to Know” principles and how they can be incorporated in
customized presentations.
Be able to evaluate the skills of others and to offer constructive criticism.
Possess an understanding of the organization, structure, and mission of the League of American
Bicyclists.
Be able to plan and organize classes, including required equipment and supplies, audio/visual aids,
course marking, understand their LCI insurance coverage, and the logistics of ordering class
materials.
Know how to market classes, including collaborating with partners and developing marketing materials.
Some of the responsibilities listed for the Coach and Site Facilitator may overlap, or require the efforts of
both so parts of this document cover both tasks.
Often the first step in the seminar process is an expression of interest from a community.
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Timeline
90 Days in Advance: Setting the Date
After making initial contact with the League, the Site Facilitator coordinates with
potential applicants, sets a date, and arranges a site. The Site Facilitator then submits a
signed Memorandum of Understanding (MOU), found at the end of this document, to
the League at education@bikeleague.org. For the seminar to be posted on the League’s
website, the MOU must contain the location (address with zip code) of the seminar site
and contact information for the Site Facilitator. The dates proposed for the seminar must
be at least 90 days after submission of the MOU – confirmation on the date will come
from the League staff.
Requests for a seminar Coach are taken into consideration; however, dates and location are factors in
which Coach the League assigns to the seminar. A Coach Directory is found on our website:
https://bikeleague.org/content/league-cycling-coaches
The Site Facilitator will seek qualified individuals and encourage them to register online for the seminar.
The Site Facilitator will further assist candidates in the application process and help them keep to the
timeline.
After specific dates are confirmed by the League and placed on the calendar, the Site Facilitator will
coordinate with the Coach in fulfilling such needs as classroom space, audio/visual equipment,
identifying League Cycling Instructor assistants, and parking lot or other on-bike drill space.
The League provides a stipend to the Coach to pay LCI assistant(s). It is at the Coach’s discretion how
to break up the stipend for LCI Assistants. Below are the stipend thresholds and dollar amounts:
Candidates attending
the seminar
Coach stipend
8 - 9
$150
10 -12
$300
13 - 15
$600
16 - 18
$900
The Site Facilitator will also research and plan a ride route that best meets the needs of the Coach’s time
allotment and the road test criteria.
The Site Facilitator may develop home-stay accommodations for the Coach and out-of-town candidates,
but is not required to.
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The Coach, upon assignment, will inform the Site Facilitator of any changes to the agenda (Attachment
B) to allow for better opportunity to schedule the facilities and the candidates to plan their
accommodations.
Most seminars will start on a Friday, usually in the late afternoon or evening, and continue through a
very full day on Saturday and most of the day Sunday.
Each seminar includes a night ride so candidates should be told to bring headlights and rear lights or
legal rear reflectors (and any other visibility gear they wish to use or discuss).
90 Days Prior to the Seminar
League staff agree to a potential site for a seminar and confirm the dates.
The Site Facilitator needs to be someone local who is willing to make the seminar happen.
Communication between the Coach and Site Facilitator is essential, since the Coach is usually not
available on-site until the seminar and is often unfamiliar with the site city.
The Site Facilitator must not be a candidate in the seminar. If that arrangement is a challenge, the League
agrees that a person can be the Site Facilitator up until the first day of the seminar. In advance of the
seminar, the Site Facilitator will identify another person to be the on-site Site Facilitator throughout the
days of the seminar in order for the original Site Facilitator to be an engaged candidate of the seminar.
The Site Facilitator must be present throughout the entire seminar.
The Site Facilitator will begin promotion of the seminar and screening for qualified applicants.
League Education staff will post the seminar details on the League website and send notification to
other potential candidates around the country who have expressed interest in attending a seminar or
who previously attended a seminar, but did not receive certification.
Potential LCIs must be experienced and knowledgeable cyclists with credibility within their local bicycling
community. Before attending the LCI Seminar, an applicant must become a member of the League ($45)
and have completed a Smart Cycling Complete course (consisting of classroom/online and on-bike
components of the class) with a score of 85% or better on both the written and road test respectively.
Site Facilitators with questions about prerequisite experience and knowledge should contact the
assigned Coach or League Education staff.
It is the Site Facilitators responsibility to check frequently with applicants and the Coach to ensure that
registrations are submitted in a timely manner. Please send direct potential registrants to the FAQ
portion of the website: http://bikeleague.org/content/become-instructor
The seminar requires a minimum of 8 paid and qualified candidates and a maximum of 16. No seminar
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will be held with fewer than 8 candidates who are qualified and registered 21 days before the seminar
date, except by special authorization from League Education staff. For a successful seminar, the Site
Facilitator should:
1 Begin screening early and obtain commitment from more than 8 potential candidates;
2 Keep candidates ahead of the registration deadline.
The Site Facilitator will reserve a suitable classroom space and a parking lot space for the seminar. It is
beneficial to have both spaces be located in the same general area.
Classroom: The classroom should be clean, have access to a bathroom, be well ventilated, and have
room for all the candidates and Coach to comfortably interact. It is suggested that the classroom also
be ADA accessible.
Parking Lot: The parking lot will be used to practice setting up and teaching bike handling drills and the
avoidance maneuvers. It must be at least 150 ft x 80 ft, have a smooth continuous surface, contain no
potholes, and be clean of debris. There also needs to be access to low volume, low speed roads for the
start of the road ride. Access to a nearby bathroom and a sheltered space is also highly encouraged.
The Site Facilitator should check with the property owner to discuss liability issues of both spaces and
have proof of insurance coverage issued by the League’s insurance agent if required. The locations
should be secured as early as possible and the ride routes sent to the Coach for examination and
approval.
At Least 28 Days Before the Seminar Date
Applicants must become members of the League of American Bicyclists by the close of registration. The
Early Bird registration rate is $500. Early Bird registration ends one week before registration closes, at
which time registration increases to $575. If another entity is paying the registration fee for some or all
of the candidates, the entity must make payment arrangements with the League by this date. LCI
numbers will not be distributed until all registration fees are paid.
At Least 21 Days Before the Seminar Date
Postpone or Cancel: At this time, League staff will approve, postpone, or cancel the seminar based on
the meeting of all requirements, particularly the “8-candidate minimum” requirement. If the seminar is
postponed or canceled, paid candidates may attend any subsequent seminar for no additional charge or
may help the Site Facilitator reschedule the seminar for that location.
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At least 14 days before the seminar date
Upon receipt of paid registration, the League Education staff electronically sends the registrants access
to the seminar materials electronically using Google Documents. Please alert your candidates that these
seminar materials arrive via email.
Each registrant will use these materials to complete the exam and send the results to the Coach to arrive
no later than 14 days before the seminar start date.
The Coach will grade the exam (a passing score is 85% but a Coach has the option of asking for additional
review if the score is less than 85%) and use the results along with the candidate’s registration form to
determine the applicants readiness to attend the seminar. The Coach may contact an applicant by
phone or email to supply feedback and/or obtain further information.
It is the Coach’s responsibility to make the final assessment and determination of applicants
qualification before the start of the seminar. If the Coach deems the candidate not ready to
take the seminar, the registration will be transferred to another seminar within the following
18 months.
During the Week Before the Seminar Start Date
Prior to the seminar, candidates will receive from the Coach a final seminar schedule outlining the times
and subject matter for each day. The attached agenda (Attachment B) is a sample agenda and is subject
to change.
The Site Facilitator will remind candidates that they are responsible for bringing their own bicycles, tools,
helmets (required) and accessories (including lights).
During the Seminar
The Site Facilitator will maintain a roster of the seminar candidates with emergency contact information
and will also pass around a daily “sign-in” sheet.
At the End of the Seminar
All candidates will also be asked to fill out a “Seminar Feedback” form, which should be returned to
the Site Facilitator for forwarding to the League office. An online survey is also available.
The Coach and Site Facilitator should hold an interview with each candidate. Candidates who do not
receive certification will be given options that may include the opportunity to attend another seminar at
no additional charge and, at the Coach’s discretion, may include a remedial tutoring option with the
Coach or a designated LCI. Remediation or follow-up attendance at another seminar must be completed
within 18 months of the seminar.
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Successful candidates will receive their LCI numbers from League staff within thirty days after the
seminar and all registrations are paid in full. Certificates are distributed to successful candidates at
the completion of the seminar by the Coach.
Site Facilitator Summary Checklist:
Identify location and dates of seminar
Return completed MOU to education@bikeleague.org
Seek qualified individuals as candidates
Distribute seminar registration link
Promotes seminar to local community
Secure AV equipment for seminar
Help identify local LCI assistants
Help Coach identify a 6-7 mile road ride for the seminar
May help identify a home-stay for Coach
Identify scholarship recipient if the 8 minimum is met
Help organize a group order for lunch or identifies spots to eat
Maintain a roster of the seminar candidates with emergency contact information
Attend the seminar and assist Coach with logistics i.e. opening/closing space, set up AV, etc.
Receive seminar materials in the mail from the League of American Bicyclists
Take group photo at the end of the seminar
Assist Coach with candidate meetings at the end of the seminar candidates
Seminar Invoicing (optional)
The host organization or another entity may want to pay for registration and/or membership fees for
specific candidates attending the seminar. Please complete Attachment D if this is the preferred method
of paying for some or all of your candidates and return to education@bikeleague.org. The organization
will be assigned a discount code and will be responsible for distributing the assigned discount code to
their select candidates. The League’s seminar cancellation policy applies to any and all discount code
use. The Cancellation Policy is as follows:
Cancellation Policy
The cancellation policy applies to all registrations whether it is being paid by an individual or by an
organization. All cancellation and transfer requests must be sent via email to education@bikeleague.org.
Cancellations made within three weeks of the first day of the seminar do not qualify for a refund.
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The registration may be transferred to another seminar within 18 months. The transfer will be
subject to a $75 administrative fee.
A cancellation made more than three weeks before the first day of the seminar is fully refundable
minus a $75 administrative fee.
A candidate may transfer their registration to another seminar prior to the registration close date
free of charge.
A candidate will be given a free transfer to another seminar or opt for a 50% refund if they
cannot attend the seminar due to health reasons.
Cancellations due to non-health related reasons made within three weeks of the seminar will be
offered a transfer and will be subject to an administrative fee of $75. Transfers must be
redeemed within 18 months of the registered seminar.
A full refund or a free transfer will be provided for any seminar canceled due to low enrollment.
Failure of a candidate to fulfill pre-assessment work will be considered a cancellation and will be
assessed a $75 transfer fee. Transfers must be redeemed within 18 months of the registered
seminar.
Seminar Scholarship(s)
The host organization or group selected by the Site Facilitator will be offered a complimentary 9
th
registration if the minimum of 8 fully paid registrations has been met. The group will be offered
a free 16
th
registration if there are 15 fully paid (with the exception of the 9th) registrations
made. Anyone receiving the complimentary registration must have previously and successfully
finished the Smart Cycling Complete Class prior to registering. Host organizations may choose to
donate the scholarship to another seminar that reaches the 8 registrant minimum.
It is encouraged that the host organization offers the complimentary registration to help meet their
local bicycling needs, whatever those may be - greater diversity in LCI demographics, location of LCIs,
etc. It is encouraged that the host organization seek out those candidates to help meet those needs.
The complimentary registration will be awarded by the host organization, meaning you will be the one
to identify the candidate(s). Remember: Smart Cycling class materials are now available in Spanish!
The complimentary scholarship is not meant to create more difficulty for the host organization, thus the
organization has the option of declining the registration(s) if administering it is a hardship. Of course, we
hope the organization can offer the free registration within their community, where we think it will have
the most value. The League cannot "break up" the free registration, it must be used for one full
registration.
There is a sample Scholarship Application at the end of this document (Attachment C). You can also
access a digital template in a Google Form here as an example. The League will provide a discount code
to you as the Site Facilitator to award the scholarship. The candidate(s) will be expected to register for
the seminar using the code prior to registration closing and the League will invoice you following the
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seminar. Please complete Attachment D if this is your preferred method of paying for some or all of
your candidates’ registration and return to educa[email protected]g
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Attachment A
Memorandum of Understanding (MOU)
Site Facilitator
League Cycling Instructor Seminar
LCI Seminar Location: __________________________________________________________________
(Venue Name, Address, City, State, Zip)
LCI Seminar Dates (must be three consecutive days)__________________________________________
(This signed MOU must be submitted to education@bikeleague.org at least 90 days in advance of the seminar dates).
1. The League is happy to hear your preference for a Smart Cycling Coach to lead the seminar but we
reserve the right to assign any of our Coaches. Click here to learn more about our Coaches.
Smart Cycling Coach (suggested): __________________________________ _______do not know
2. Would you like registration to be open to the public or closed to the public (meaning only your
selected candidates will register)? [Our system cannot “hold spots”- if you would like registration to be
limited to a specific group of people, please select closed] OPEN_________ CLOSED_________
3. Will your organization be paying for some or all of the registrations? _____Yes _____No
(If you would like to be invoiced by the League for payment, please complete Attachment D)
4. Will your organization be paying for some or all of the memberships? _____Yes ______No
(If you would like to be invoiced by the League for payment, please complete Attachment C)
I have read the document in its entirety and agree to perform the responsibilities as Site Facilitator for
the LCI Seminar listed at the above location and dates. Additionally, I understand that Site Facilitators
are not paid by the League.
Name: ______________________________________________________________________________
Affiliated Organization _________________________________________________________________
Signed: ______________________________________________ on ____________________________
(by entering your name into this field and dating the document, you are signing)
Telephone work: _______________________ Telephone Cell: _____________________________
Email Address: ______________________________________
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ATTACHMENT B
League Cycling Instructor Certification Seminar Draft Agenda
(Subject to Change)
Day 1: Friday 5:00pm (start times / hours:minutes to this session)
Times below may be adjusted at the Coach’s discretion to accommodate weather conditions. The below
outline provides a general timeline of the seminar weekend.
1. Sign-In 5:00pm / 0:30
2. Introductions 5:30pm / 0:45
a. Where We Are Going/Objectives of the Seminar
b. Trainer and Attendees, Interview Methods/Ice Breakers
c. Review of Smart Cycling
d. Review of Pre-Test (time permitting)
3. Basic Teaching Skills I 6:15pm / 1:00
a. How We Learn
b. What We Bring to the Classroom
c. Essentials of Communication
d. Listening Skills
4. Break 7:15pm / 0:15
5. Basic Teaching Skills II 7:30pm / 1:15
a. Teaching Strategies
b. Classroom Preparation
c. Effective Questioning Techniques
d. Constructive Criticism
e. Dealing with Difficult Students
6. Student Presentation Time Assignments 8:45pm / 0:15
7. Break for the Evening 9:00pm Coach will be available to advise participants until 9:30 pm
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Day 2: Saturday, 8am 9:30pm
1. Sign-In 8:00am / 0:15
2. Student Teaching I (Paired Presentations) 8:15am / 2:00
3. Break - Road Ride Preparation 10:15am 0:15
4. Road Ride 10:30am / 1:30
a. Map of Route (approximately 6 miles)
b. Group Riding Skills
c. Road Test Scorecard, Grading System
d. Expectations of Road Ride
e. Ride and Watch
f. Debrief
5. Lunch 12:00 noon / 1:00
6. Prepare for Parking Lot Drills 1:00pm / 0:15
7. Handling Drills 1:15pm / 1:00
a. Mounting/Dismounting
b. Starting/Stopping
c. Holding Your Line
d. Scanning/Signaling
8. Avoidance Drills 2:15pm / 1:30
a. Swerving
b. Rock Dodge
c. Emergency Stop
d. Instant Turn
9. Break 3:45pm / 0:15
10. Student Teaching II (Individual Presentations) 4:00pm / 1:30
a. Presentation
b. Critique
11. Dinner Break 5:30pm / 1:00
12. Student Teaching III (Individual Presentations) 6:30 pm / 1:30
a. Presentation
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b. Critique
13. Preparation for Night Ride 8:00pm / 0:15
14. Night Ride 8:15pm / 1:00
a. Reflectors
b. Equipment
c. Lighting Systems
15. Break For Evening 9:15pm Coach will be available to advise participants until 9:45 pm
Day 3: Sunday 8am 3:00pm
1. Sign-In 8:00am / :15
2. Working with the League 8:15am / 0:45
3. League Curricula Modules 9:00am / 0:45
a. Smart Cycling (formerly TS101)
b. Commuting
c. Motorists
d. Kids
e. Group Riding Skills
4. Children A Special Case 9:45am / 0:15
5. Break 10:00am / 0:15
6. Road Ride Exam 10:15am / 1:45 (same route as Saturday)
7. Lunch 12:00 / 0:30 (with Road Ride De-Brief)
8. Marketing Your Classes 12:30pm / 1:00
9. Seminar Agreements/Feedback 1:30pm / 1:15
10. Goodbye and Good Luck Photo Opportunity 2:45pm
11. Finish 3:00pm
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ATTACHMENT C
League Cycling Instructor Scholarship Application Template
{Insert Host Organization Logo}
This template is to help guide a host organization to create an application to offer seminar
scholarships within their community. A sample Google Form is also available here.
PLEASE NOTE: The Google Form should be copied to your Google Drive so that you can make
changes and distribute the form through your email.
{Name of Host Organization}
League Cycling Instructor Scholarship Application
League Certified Cycling (LCI) Instructor Seminar at {Location, Dates}
{List contact information here. Provide contact information of the person responsible for
administering the scholarship, email and/or phone number. This is someone affiliated with or
part of the seminar host organization.}
{List instructions on How to Submit the Form & Due Date - Due date should be at least 5 weeks
before the seminar so that the candidate has time to be notified and register for the seminar.}
Name (First, Last):
Address:
Phone Number: Email:
Are you affiliated with a local organization, club, or store?
If yes, list the name of the organization, club, or store:
Have you completed the Smart Cycling Complete Course (formerly Traffic Skills 101)?
The Complete Course consists of classroom instruction and on-bike handling skills. Students are tested.
Students may substitute the classroom instruction portion with the online course at bikeed.org. The
on-bike portion must be completed with a current LCI.
Yes_____ No _______ Date of completion: _________________________
Name of League Cycling Instructor: ____________________________________
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Why are you seeking to be certified as an LCI?
How will you commit to serving your community through teaching bike safety education
in the following year? i.e. teach adult bike education classes, teach youth, teach
motorists how to share the road, etc.
How many classes do you commit to teaching next year?
What region, city, or neighborhood will you serve?
We strive to understand the demographics of LCI candidates in order to ensure that bike safety
education is reaching all communities. Please help us understand you and your background by
answering the following demographic questions.
Gender
______Woman
______Man
______Non-Binary/non-conforming
______Prefer not to Answer
Ethnic Identity
______African American
______American Indian/Alaskan Native
______Asian
______White
______Hispanic/Latino
______Native Hawaiian/Pacific Islander
______Prefer not to Answer
______Other
List Other:______________________
Age ________
Are you comfortable instructing a Smart Cycling class in a language other than English?
_______ Yes ______No If yes, what language(s)? ________________________________
Is there anything else you would like us to know about your interest in becoming a
League Cycling Instructor?
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The awarded scholarship is for the seminar early bird registration fee of $500. Candidates
are responsible for their membership to the League of American Bicyclists ($50).
Candidates will also be expected to maintain their League membership annually ($50) and
their annual LCI renewal fee ($25).
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ATTACHMENT D
League Cycling Instructor Certification Seminar Agreement of Payment
This document is for entities that are paying for candidates’ LCI seminar registration fees and/or
membership to the League of American Bicyclists. Below are important details to consider:
Early Bird Registration Fee: $500
Starting the final week of registration, the rate increases to: $575
Registration closes three weeks prior to the start of the seminar.
League Individual Membership: $50
All LCI candidates must have an individual or family membership to the League. This is for
insurance purposes. We cannot accept organizational or business membership for LCI candidates.
All LCI candidates attending an LCI seminar must be registered.
Please complete the below information so that the League of American Bicyclists can properly process
registrations and League memberships for the LCI seminar. You will be sent a registration code via email
that you can pass onto candidates for whom you want to cover or discount registration and/or
membership. The paying organization will be invoiced for the number of registrations and/or
memberships that are redeemed using the code(s) within 30 days of the seminar.
Due to the amount of information the League collects about a candidate’s bicycling experience relevant
to the LCI seminar, we ask that your candidates register themselves using the codes for registration and
membership.
All registrations that are made using your specific registration code are subject to the League’s
registration fees and Cancellation Policy.
Cancellation Policy
The cancellation policy applies to all registrations whether it is being paid for by an individual or an
organization. All cancellation and transfer requests must be sent via email to education@bikeleague.org.
Cancellations made within three weeks of the first day of the seminar do not qualify for a refund.
The registration may be transferred to another seminar within 18 months. The transfer will be
subject to a $75 administrative fee.
A cancellation made more than three weeks before the first day of the seminar is fully refundable
minus a $75 administrative fee.
A candidate may transfer their registration to another seminar prior to the registration close date
free of charge.
A candidate will be given a free transfer to another seminar or opt for a 50% refund if they
cannot attend the seminar due to health reasons.
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Cancellations due to non-health related reasons made within three weeks of the seminar will be
offered a transfer and will be subject to an administrative fee of $75. Transfers must be
redeemed within 18 months of the registered seminar.
A full refund or a free transfer will be provided for any seminar canceled due to low enrollment.
Failure of a candidate to fulfill pre-assessment work will be considered a cancellation and will be
assessed a $75 transfer fee. Transfers must be redeemed within 18 months of the registered
seminar.
Location of the Seminar (City, State): __________________________________________________
Seminar Dates: ___________________________________
Site Facilitator: ___________________________________
Name of paying organization:___________________________________________________________
Billing Address:_______________________________________________________________________
Contact Name (The invoice will be sent to this person): _______________________________________
Contact Email address: ________________________________________________________________
Seminar Registration Fee
Would you like to pay for candidates’ LCI seminar registration fee? ______YES ______NO
If yes, what percent of the registration fee will you be covering? ________%
Approximately how many registrations will you be paying for?__________________________________
Membership Fee
Would you like to pay for candidates’ League membership fee? ______YES ______NO
If yes, approximately how many memberships will you be paying for?_____________________________
I have read the League Cycling Instructor Certification Seminar Agreement of Payment, Attachment D. I
understand the Cancellation Policy and that the organization will be billed accordingly at the completion
of the seminar.
Name: _________________________________________ Title: _________________________________
Signed: ______________________________________________ Date:___________________________
(by entering your name into this field and dating the document, you are signing)
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