Churchill County Parks and Recreation

2013 Youth Tour Bike Ride Pre-Registration Form

Race Registration Information

Name: _________________________________________ Address: _______________________________________ ________________________________________ City: ___________________________________________ State: _____________________Zip: _________________ Phone: _________________________________________ Shirt Size (Circle One): YS YM YL YXL S M L XL XXL 4 Mile 6 Mile

Make checks payable to: Churchill County Parks & Recreation (CCPR) 325 Sheckler Road Fallon, NV 89406 For more information, call (775) 423-7733 **

Ride Distance (Circle One): 2 Mile Gender (Circle One): M F

Age: ________

E-mail Address: ____________________________________

Waiver: In consideration of your accepting my entry, I, intending to be legally bound, hereby for myself, my heirs, executors, and administrators,
waive and release any and all rights and claims for damages I may have against the Churchill County Cyclists, Churchill County Parks & Recreation, and any of their officials and representatives for any and all injuries suffered by me in the Youth Ride including liability while traveling to and from the event. I understand I must have my dog on a leash, if participating in this event. * I also understand that due to the nature of this program I/my child may be included in photos or video that will be used for media information or advertising of future programs. I understand by signing this hold harmless agreement I authorize the use of any photos or video taken during this event.

Signature: __________________________________ Date: ____________

Note: Parent or guardians signature required if participant is under 18 years of age. Youth Bike Tour Information Date: June 15, 2013 Start Time: 10:00am Registration: 9:00am 9:50am Location: Corner of Drumm and Pasture (Veterans Memorial Park) Entry Fee: $15.00 per youth, $5.00 per adult (No shirt), $40 per family (4 shirts), $5 addl shirt T-shirt Deadline: Must Register by 5/31/2013
SPONSORED BY CHURCHILL COUNTY PARKS & RECREATION

All proceeds go to support youth programs in our community!!