OR FILL IN FORM BELOW, PRINT OUT & MAIL WITH CHECK PAYABLE TO WCBC
Mail
to:Mike
Katz ,701 Naples Way, Bear, DE 19701
NAME:
ADDRESS:CITY:STATE:
ZIP :
EMERGENCY PHONE:
-
EMAIL: Distance (check one):
35 miles
65 miles
100 miles
$15 registration (if received by August 1); $20 after Aug. 1
$10 Shorefire tee-shirt (pre-order only, by August 1)
S
M
L
XL
XXL
Amount enclosed
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 Shore Fire Century 8/23/08.
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: _________________________