2010 Blackhawk Country Roads Registration/Release Form
(Please print form) rev 17 March 2010
Name ___________________________________________________________
Street ____________________________________________________________
City _________________________________ State ________ Zip __________
Phone ___________________ Bike Club Affiliation _______________________
E-Mail________________________________________ Ride Fee $______
Adult Sizes S M L XL T-shirt Fee $______
Total Paid $______
-----------------------------Register---------------------------
before Apr 30 before May 14 after May 14
Individual rider w/T-shirt________$22____________$29____________$34
Individual rider no T-shirt ______________________$16____________$21
Family of 3 no T-shirt _________________________$36____________$41
Additional T-shirt_____________________________$13
Additional riders under 18_______________________$6_____________$8
Additional day ride fee $10
Release of organizers and sponsors:
In signing this form for myself or the above named participant (if he or she is under 18), I understand and agree to absolve all of the sponsors and organizers, be they individuals or organizers, singularly and collectively, of all blame for any injury, misadventure, harm, loss or inconvenience suffered as a result of taking part in this event or in any of the activities associated with said event.
Signature ________________________________________ Date ________________
Make
check payable and mail to:
Blackhawk Bicycle and Ski Club
Attn: Blackhawk Country Roads
PO Box 6443