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The Peninsula Bicycling Association
WILLIAMSBURG WEENIE RIDES 2012
May 26, 2012 |
| Name: |
Phone: |
| Address: |
Email: |
| City/State: |
Zip: |
| Emergency Contact: |
Phone: |
| I will ride the following route (please circle one): 12 25 35 45 64 |
| Registration fee: |
Non-member |
$15 |
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PBA member |
$10 |
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Child (12 and under) |
$5 |
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Late fee (after 5/16) |
$5 |
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T-shirt |
$15 |
Circle size: S M L XL XXL (add $2) |
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Total Enclosed: |
$ |
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RELEASE AND WAIVER:
In signing this application, I hereby make it known to whoever it may concern, that during Peninsula Bicycling Association activities-with full realization that there are known and unknown hazards to these activities-I do hereby: assume all risk for injury, loss or damage foreseeable or not, which I and/or any children under the age of 18 in my care may sustain as an accident to such activities. I warrant to make no claim at law or equity against the Peninsula Bicycling Association or any participant arising out of any injury, loss, or damage from whatever cause during a Bicycling activity, PROVIDED HOWEVER that this release shall not be construed to limit my right to proceed any class of persons specifically excluded herein, who negligently cause injury, loss, or damage to the persons named on this application.
Applicant or parents or guardians of minors (under the age of 17) must sign below.
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| Only one person/form - Form may be duplicated |
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