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
------2010 SAVAGE CENTURY REGISTRATION------
Please PRINT CLEARLY
ENCLOSED IS $
($20/person if received by October 6; $25 thereafter)
NOTE: Children under the age of 18 are free but must be accompanied by
a paid adult.)
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 10/16/10. 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: _____________________________________
