2007
Visually Impaired
Sunday, July 22,
2007 – 8:30 a.m. – Rain or Shine
Registration/Release Form
Please print this form, fill it out and mail it with your check or money order for at least $45.00 per participant to the following address.
Please make checks payabel to Visually Impaired Center. Thank you!
Visually Impaired Center
Genesee Lapeer Bicycle Ride for the Visually Impaired
1422 W. Court St
Flint, Mi 48503
The bicycle ride requires a minimum donations of $45.00 per participant. To mee or exceed that cost we do encourage you to collect additional donations from friends, family and co-workers to raise funds for the Visually Impaired Center. Free t-shirts will be given only to pre-registered riders (registration and fees received by the VIC on or before Friday, July 6, 2007). You may register on the day of the event.
__________________________________________________________________________62/43/17________S/M/L/XL/XXL____
Last Name First Name Release Signature Route T-shirt Size
_____________________________________________________________________________________________
Street Address City/State/Zip Phone Number
_____________________________________________________________________________________________
Emergency Contact Relationship Day/Cell Phone Number
Please list additional riders/walkers who reside at the same address as above here. If additional riders/walkers reside at a different address, please use a separate form:
__________________________________________________________________________62/43/17_________S/M/L/XL/XXL_____
Last Name First Name Release Signature Route T-Shirt Size
__________________________________________________________________________62/43/17_________S/M/L/XL/XXL_____
Last Name First Name Release Signature Route T-Shirt Size
__________________________________________________________________________62/43/17_________S/M/L/XL/XXL_____
Last Name First Name Release Signature Route T-Shirt Size
*Please Note:
All
riders must sign the release. A parent’s
signature is required for riders under the age of 18. Riders
under the age of 16 must be accompanied by an adult. All riders must contribute the minimum $45.00
entry fee.
I
understand and agree that the Visually Impaired Center and
all other individuals and groups associated with the “Genesee Lapeer Bicycle
Ride for the Visually Impaired” will not be liable for any loss, injury,
or death related to this event. I know
of and willingly accept any and all risks associated
with participation in this event. I
fully understand that the Visually Impaired Center has organized this ride and
walk but it is my responsibility to know and obey all laws to ensure my
safety. I am physically capable to
participate in the event I have chosen.
HELMETS ARE REQUIRED FOR ALL CYCLISTS!
NO REFUNDS WILL BE AVAILABLE
AFTER PARTICIPANT MONEY IS TURNED IN TO THE VIC!
For a complete list of “
____
Yes, please send me a receipt for my entry fee(s).
____No,
please do not give my mailing address out to any event sponsors.