KIWANIS CRAZY KICKER, SATURDAY, OCTOBER 18, 2008
REGISTRATION FORM

NAME________________________________________AGE ________
ADDRESS_____________________________________SEX_________
CITY_________________________STATE___________ZIP__________
PHONE_______________________CELL_________________________
EMERGENCY CONTACT_____________________________________
EMERGENCY CONTACT PHONE NUMBER_____________________

    EMAIL PLEASE ______________________________

SHIRT SIZE          M         L        XL       XXL
RIDE DISTANCE      100MI       65MI (100K)         50MI          37MI        22MI    ( 10MI - $10 )

EARLY REGISTRATION (POSTMARKED BY OCT 10^TH)     $20.00

LATE REGISTRATION                                                               $30.00

FAMILIES OR GROUPS OF 4 OR MORE                                 $15.00 PER RIDER
MUST BE PAID WITH ONE CHECK PRIOR TO OCT. 10^th

  MAKE CHECKS PAYABLE TO KIWANIS

PO BOX  836
MINERAL WELLS, TEXAS  76068

NOTICE:  THIS ENTRY BLANK AND RELEASE FORM IS A CONTRACT WITH LEGAL CONSEQUENCES, READ IT CAREFULLY BEFORE  SIGNING.

In consideration of acceptance of my entry, I, the undersigned, assume full and complete responsibility for any injury or accident  which may occur to me during the Kiwanis Crazy Kicker Ride oar while I am on the premises of the event.  On behalf of myself, my heirs, executors, and assigns, I release and hold harmless the sponsors, promoters and all other persons and entities associated with a this event from any and all injury and damages sustained by me whether such injury or damages are caused by negligence of the sponsors, promoters, or other person and entities associated with the event or otherwise I acknowledge that I am familiar with the dangers involved in competing in this event, that there may be holes in the riding surface or other permanent or temporary obstacles which I must be careful to avoid and I agree to familiarize myself with the course prior to the commencement of the event.  I understand that the event takes place on public streets and roads with vehicular traffic.  I certify that I am in good physical condition and am fully able to participate in this event.  I also grant full permission to any and all sponsors to use photography and records of this event for any purpose.  I have read and understand all of the above.

Participant’s Signature_____________________________________________Date___________________

Parent or Legal Guardian Signature__________________________________Date___________________