Please print and mail this form to the address provided above.

____________________________________________________________
Name
____________________________________________________________
Address
____________________________________________________________
City, State, ZIP
____________________________________
Phone
____________________________________________________________
Donating for (person's name)
____________________________________________________________
Event City & Date
____________________________________________________________
E-Mail Address
____________________________________________________________
Name and Phone of Emergency Contact (required)
 

WAIVER AND RELEASE OF LIABILITY
I am a voluntary participant in this event, and in good physical condition. I know that this event is a potentially hazardous activity and I hereby assume full and complete responsibility for any injury or accident which may occur during my participation in this event or while on the premises of this event, and I hereby release and hold harmless and covenant not to file suit against Bike4BreastCancer, Inc., its local affiliates and any affiliated individuals, their agents and employees, and all other persons or entities associated with this event (the "Releasees") from any loss, liability, damage, or claims I may have arising out of my participation in this event, including personal injury or damage suffered by me or others, whether same be caused by falls, contact with other participants, conditions of the ride route, negligence of the Releasees or otherwise. If I do not follow all the rules of this event, I understand that I may be removed from the event. I give my full permission to Bike4BreastCancer, Inc., and its local affiliates and their sponsors and corporate partners to use any photographs, videotapes, or other recordings of me that are made during the course of this event. Helmets are required and will be worn by participants at all times while operating a bicycle and there will be no exceptions.

________________________________________________________
Signature of Participant or Parent / Guardian (if under 18 years old)

________________________________________
Date

Early Registration Fee - $30.00 per cyclist* or $30 minimum in sponsorships.
On Site Registration Fee - $35.00 per cyclist or $35 minimum in sponsorships.

Family Registrations - $50.00* per family or $50 minimum in sponsorships.  FAMILIES CONSIST OF TWO (2) ADULTS ONLY (CHILDREN 13 AND UNDER INCLUDED.)
On Site Registration - $60.00 per family or $60 minimum in sponsorships.

Click here for a sponsorship worksheet.

Total Number of Cyclists: _____

Please indicate which distance you are registering for:
55_____ 42______ 20_____ 7 _____

****PRIZES FOR TOP FUNDRAISING EFFORTS****

Additional Donations:  $_______________

Total Enclosed:   $____________________

___ I AM A SURVIVOR - Please check if you are a cancer survivor.

For additional information:  Sue Morris - penbryn@charter.net, (231) 709-8714