FILL IN FORM BELOW, PRINT OUT & MAIL WITH CHECK PAYABLE TO WCBC

MAIL TO: Cindy Mannis, 1 Langton Hill Road, Landenberg, Pa 19350

NAME:  

ADDRESS: CITY: STATE: ZIP :

EMERGENCY PHONE: - EMAIL:

Distance (check one): 35 miles       65 miles        100 miles

$20 registration (if postmarked by August 1); $25 after Aug. 1

$10 Shorefire tee-shirt (pre-order only, by August 1)
                 S      M       L      XL       XXL     

Amount enclosed

PARTICIPANTS MUST SIGN RELEASE BELOW:
In consideration of the acceptance of my entry: I do hereby, for myself, for my heirs, executors, and administrators waive, release, and forever discharge any and all rights and claims for property damage and/or personal injury which I may have or which may occur to me, against the White Clay Bicycle Club, or any of their officers, members, sponsors, agents or representatives, arising out of traveling to, participating in, or returning from the Shore Fire Century 08/28/10. Should there be such an incident, I will notify WCBC via the above contact within 48 hours. I agree to wear a HELMET for this event.

Signature of rider: _________________________________________ Date: ___________

Signature of adult supervising minor on ride: _________________________