Official Registration and Release - Fall Back 40 - 2006
Please Print Legibly - Make checks payable to "FRCC"
- Mail to: FRCC, P.O. Box 815, Clarkston, MI 48347
This flyer may be duplicated - One entry per form please
| Name: | Age: |
| Address: |
| City: | State: | Zip Code: |
| Phone Number: ( ) - |
| Emergency Contact: | Phone Number: ( ) - |
| Item | Cost | Quantity | Total |
| Registration - Postmarked Before September 29, 2006 | 18.00 | ||
| Registration - Postmarked After September 29, 2006 | 20.00 | ||
| Registration - FRCC Members | 10.00 | ||
| Registration - Age 60 and over | 12.00 | ||
| Registration Age 12 and under | 12.00 | ||
| T-Shirt - Postmarked Before
October 3rd Circle Size: M L XL XXL |
15.00 | ||
| TOTAL COST( Make checks payable to "FRCC") |
RELEASE: In signing this form for myself or the above named participant (if under 18 years of age), I acknowledge that I understand the intent hereof, and I hereby agree to and will absolve and hold harmless the "Fall Back 40 - 2006" directors, Kinetic Systems Bicycles, the Flying Rhino Cycling Club and officers, and any and all other parties connected with this event in any way singly or collectively, from and against and blame or liability for an injury, misadventure, harm, loss, inconvenience, or damage suffered or sustained as a result of participation in the "Fall Back 40 - 2006" or any activities associated therewith. I also hereby consent to permit emergency treatment in the event of injury or illness. I shall abide by all traffic laws and regulations and will practice courteous and safe cycling.
Signature of Participant: |
Date: |
Signature of Parent or Guardian: |
Date: |