REGISTRATION
Icicle Metric 2011

PRINT AND MAIL IN FORM BELOW

Registration Form (Print Out / Fill Out / Mail)

Please register me for WCBC's Icicle Metric Century (Please Print Clearly)


Name: _________________________________________________________________

Address: _______________________________________________________________

City: ____________________________  State: __________  Zip: ____________

Phone (      )______________________________

MAIL TO:Ted Ryser, 356 Matthew Flocco Dr., Newark, De 19713-2350 

Amount Enclosed:  $   _______  $20 
($15 if received by mail by March 19, 2011)  Make check payable to WCBC 

I intend to ride the following route: ____22 miles, ____31 miles, ____62 miles

PARTICIPANTS MUST SIGN RELEASE BELOW:
In consideration of the acceptance of my entry: I do hereby, for myself, for my heirs, executors, and administrators waive, release, and forever discharge any and all rights and claims for property damage and/or personal injury which I may have or which may occur to me, against the White Clay Bicycle Club, or any of their officers, members, sponsors, agents or representatives, arising out of traveling to, participating in, or returning from the ICICLE METRIC (03/26/11). Should there be such an incident, I will notify WCBC via the above contact within 48 hours. I agree to wear a HELMET for this event.

Signature of rider: _____________________________________      Date: _________________

Emergency Contact Name/Phone #___________________________________________________

Signature of adult supervising minor on ride: __________________________________