2012 Blackhawk Country Roads Registration/Release Form

(Please print form)   

                                                                                                                rev 26 January 2012        

Name   ___________________________________________________________

 

Street ____________________________________________________________

 

City   _________________________________  State ________  Zip __________

 

Phone  ___________________  Bike Club Affiliation _______________________

 

E-Mail________________________________________      Ride Fee    $______        

 

Adult Sizes     S    M    L    XL    XXL           T-shirt Fee  $______        

                                                                                                       

Total Paid  $______

 

                                             -----------------------------Register---------------------------

                                             before Apr 20         before May 11        after May 10

Individual rider w/T-shirt________$22____________$29____________$34    

Individual rider no T-shirt ______________________$16____________$21    

Additional T-shirt____________________________$13                         

Riders under 16______________________________$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

Rockford IL 61125-1443