WAVIER OF CLAIM

In consideration of my entry, I, intending to be legally bound, hereby for myself, my heirs, executors and administrators, do hereby waive, release and forever discharge any and all rights and claims for damages or other relief which may accrue to me against the Columbus Lions Club Rolling Hills Challenge, their respective officers, representatives and agents, and/or assigns for any and all injuries arising from my participation in the Columbus Lions Club Rolling Hills Challenge. I also agree that I may be examined and treated before, during or after the ride by qualified personnel. I hereby grant consent for such examination and treatment. I agree that the ride officials or the qualified personnel have the right to disqualify and remove me from the ride if in their opinion it may not be advisable for me to participate in the Columbus Lions Club Rolling Hills Challenge for medical reasons. I attest and verify that I am physically fit and sufficiently trained to participate safely in the Columbus Lions Club Rolling Hills Challenge.

I further understand that a bicycle is a legal vehicle of the road in the State of Texas, and I will ride in accordance with the Texas Vehicle Code. I recognize that the sponsors and promoters of this event strongly recommend the use of an ANSI or SNELL approved bicycle helmet while riding a bicycle and that riding without a helmet greatly increases my risk of injury.

X_____________________________
Entrant's Signature
 

X_____________________________
Signature of Parent/Guardian of Minor
 

____/____/____
Date
 

X_____________________________
Entrant's Signature

X_____________________________
Signature of Parent/Guardian of Minor

____/____/____
Date

 
RIDER #1 NAME (Last, First, Middle Initial)
.
AGE
.
RIDER #2 NAME (Last, First, Middle Initial)
.
AGE
.
ADDRESS  
.
E-MAIL
CITY, STATE, ZIP
.
PHONE
.
EMERGENCY CONTACT
.
PHONE
.

RIDE DISTANCE
 (Circle)

#1:  25   50   62.5   100

#2:  25   50   62.5   100
 

T-SHIRT SIZE
(Circle)

#1:  MEDIUM    LARGE   X-Large   XX-Large (add $2)

#2:  MEDIUM    LARGE   X-Large   XX-Large (add $2)
.

 

Make checks payable to:
COLUMBUS LIONS CLUB

ITEM AMOUNT
Pre-Registration $25 Single
$45 Tandem
Registration $30 Single
$55 Tandem
TOTAL
ENCLOSED
 
  Administrative Use Only


 

 

Please print and mail this completed & signed form,
with pre-registration fee (before March 31, 2007) or
with full registration fee (after March 31, 2007) to:

COLUMBUS LIONS CLUB ROLLING HILLS CHALLENGE 2007
P. 0. Box 532
Columbus, Texas 78934-0532

2007