2010 Indian Lake Bicycle Tour registration form
Name: ____________________________________________________________________ _____ Male _____ Female
Address: ____________________________________________________________________________________________
City: _________________________________________________________ State: _______ ZIP: _____________________
E-mail address: _______________________________________________________________________________________
Age: _____ Phone: ______________________________ _____15 mile ride ____ 30 mile ride ____ 60 mile ride
Release and consent (must be signed by all riders). Helmets required.
In consideration of the acceptance of the entry form and in signing of this release and consent for myself or for the named entrant (if the entrant is under the age of 18), I acknowledge that I understand the intent hereof, that I hereby agree and will hold harmless, the Indian Lake Area Chamber of Commerce, its individual members, its officers, and support entities, respectively, singularly, and collectively from and against any blame of liability for any injury, misadventure, harm, loss, inconvenience or damages suffered or associated therewith. I also state that I will abide by all traffic laws and regulations and practice courtesy and safe cycling
Signature ______________________________________________________ Date ____________________________________________
Parent or guardian if under 18 _____________________________________________________________________________________
_____ 13 & up Enclosed $25 (pre-registration) _____ 13 & up $25 day of the ride no shirt
_____ 6 - 12 Enclosed $15 (pre-registration) _____ 6 - 12 Enclosed $15 (pre-registration)
_____ 5 And under Free (No Shirt) ____ Non riders $10 (No shirt) ____ T Shirt $12
T-shirt size (circle one please) S M L XL XXL
Make checks payable to:
Indian Lake Area Chamber of Commerce
Mail to: Indian Lake Area Chamber of Commerce, P.O. Box 717, Russells Point, OH 43348
Phone: (937) 843-5392