Sawnee & Burnt Mountain Century Challenge
Rider Entry Form
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Entry Form: See Sept/Oct issues of FreeWheelin’. A Donation: $26 if postmarked by Oct. 12th. $31 after or on day of ride. $1 goes to GA Bikes! Make checks payable to the Cumming Kiwanis Club and mail to: Dick Gellner, 8760 Amberfield Dr., Cumming GA, 30506. Contact: Dick Gellner 770-781-2569; email: dickgellner@bellsouth.net or visit our web site: www.cummingkiwanis.org for more information on the ride, camping or hotels.
On Line Registration: www.active.com
First
Name__________________________ Last Name_________________________________
Address___________________________________________________
City______________________________ State____________ Zip Code___________
Phone___________________ E-mail_______________________________________________
Age: ____ Male___ Female___ “T” Shirt Size, circle one: Small Medium Large XL XXL
Emergency Contact: Name ___________________________________ Phone No. ____________________
Distance: _____10 Miles _____ 30 Miles _____ 44 Miles _____69 Miles _____ 100 Miles, for experience cyclists only!
Waiver /
Release Form: In consideration of this entry, I waive any and all claims for
myself and my heirs, Kiwanis Club, Forsyth, Dawson, Pickens Counties,
sponsors and
their respective officials for illness, injury or death directly or indirectly
for my participation in Sawnee & Burnt Mountain Century Challenge. I understand
that bicycling can be a hazard that could result in injury or even death. I am
in proper physical condition to participate in this event. Helmets are
required.
Signature________________________________________ Date_____________
If under 18 must be signed by parent or guardian:
Signature________________________________________ Date_____________ Relationship_______