REGISTRATION

2008 Savage Century

Fill in the form below , print it out and mail it with a check payable to WCBC to:

Jerry Steinberg
1916 Kynwyd Rd
Wilmington DE, 19810

------2008 SAVAGE CENTURY REGISTRATION------

Please PRINT CLEARLY

ENCLOSED IS $ ($15/person if received by October 9)

NAME:   

NAME:   

ADDRESS:

CITY:

STATE: ZIP:

PHONE: Home -

PHONE: Work -

E-MAIL:

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 Savage Century 10/18/08. 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: _________________

Signature of adult supervising minor on ride:

_____________________________________________