REGISTRATION-Savage Century

2011 REGISTRATION - SAVAGE CENTURY
Fill in the form below , print it out and mail it with a check payable to WCBC to:
Craig Hall, 220 Valley Lane, Hockessin, DE, 19707

ENCLOSED IS $ ($20/person if received by October 1, 2011; $25 thereafter)
NOTE: Children under 18 are free but must be accompanied by a paid adult.)

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 10/15/11. 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: _____________

Signature of adult supervising minor on ride:

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