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

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

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

________________________________________
Parent or Guardian (if under 18 years old)

_______________________________________
Date

Early Registration Fee - $30.00 per cyclist (ages 13 and up),  $10.00 (ages 6 to 12), FREE (ages 5 and under) by Sunday, September 6, 2009.

On Site Registration Fee - $35.00 per cyclist

T-shirt (long-sleeved):   must be pre-registered by Sunday, September 6, 2009 - $17.00
The shirt this year will be a chocolate brown long sleeved shirt with our logo in pink and sponsors in white lettering.

              M ______ L ______ XL ______ XXL ______ (additional $2.00)

Total Enclosed $____________________

I can not ride but I would like to help: _____Donation ____Volunteer

For additional information: 1-888-906-2453 or Adele Snowman, bike4breastcancer@hotmail.com