Registration Form

1st Annual Millerstown Community Park Bike Tour Registration Form

Ghost Rider -25K- 50K-100K Rides
Saturday, June 25, 2011
Millerstown Community Park
Millerstown, PA

Name: __________________________________________________________
Address: __________________________________________________________
__________________________________________________________
Phone: __________________ Email __________________
Emergency
Name and Telephone: ____________________________________
Contact
Day of Ride $25 ________
Fees: Pre-reg. $20 by 6/18/2011 ________

I Pledge to raise at least $100, due by day of Ride _______ (Waive my registration fee)

Make checks payable to: Millerstown Recreational Committee

I plan to ride Ghost Rider _____ 25K _____ 50K _____ 100k _____
T-shirt Size: Sm.____ Med. ____ Lg. ____ X-L ____ XXL_____
Free T-shirt to the 1st 100 pre-registered participants

I know that participation in the tour is potentially hazardous. I should not enter unless I am medically able
and properly trained. I abide by any decision of tour officials relative to my ability to safely complete the
event. I assume all risks associated with the event including, but not limited to contact with other
participants; the effect of the weather, including high heat and humidity and cold; traffic and the condition
of roads. I know that I am required to wear a helmet. If I am a minor under the age of 18 I must have a
parent or guardian sign below, and if I am 14 or younger, I must be accompanied by an adult. All such
risks being known and appreciated by me, having read this waiver and knowing these facts and in
consideration of my entry, I for myself and anyone entitled to act on my behalf, waive, and release the
Millerstown Recreational Committee, and all boroughs and townships, all representatives and successors
for all claims or liabilities of any kind arising out of my participation in this event.

Signature of Participant: _____________________________ Date:________

*If under 18, Parent/Guardian of minor must
_____________________________ Date:________
sign
To register, print this page and mail to:

C/O Scott Sanderson

202 Old Ferry Rd.
Millerstown PA, 17062