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Registration

Please print information clearly!

Name                                                                       

Address                                                                    

City                                                 State                                         Zip Code                              

Phone (         )                          Male/Female  (circle one)

Age                Email Address                                                                                      

Circle T-Shirt Size:        M         L          XL

 

Enclosed Fee (non refundable) -

Postmarked by 10/09/10       $20

Postmarked after 10/09/10    $25

Checks payable to "First Presbyterian Church of Reidsville". Please specify Ride the Rock on check description line. Mail to First Presbyterian Church, 318 S. Main Street, Reidsville, NC 27320

ASSUMPTION OF RISK: I am aware that participation in the Ride the Rock Bike Ride is dangerous and I am voluntarily participating in this activity with the knowledge of the dangers involved and hereby agree to accept any and all risks of injury or death suffered by me as a result of my participation in this activity. I release First Presbyterian Church of Reidsville from any claim of injury that may result. I understand that an "Ansl/Snell" approved helmet MUST be worn by me at all times on the course. I understand that this is not a closed course and I must abide by the rules of the road. I hereby give permission to the First Presbyterian Church of Reidsville to use my name and any photography taken of me during the event in any promotional materials or publications. I certify I have read this waiver and release and understand its significance. No Refunds.

Signature of Participant                                                         

Signature of Guardian