The Ger Coughlan Memorial Cycle

in aid of Milford Hospice 14th April 2012

Completed registration forms must be returned to: Keith Coughlan, Corcamore, Clarina, Co. Limerick Tel 087 2254860 or email kcoughlan11@gmail.com Name: ______________________________________ Postal Address: ______________________________________ ______________________________________ ______________________________________ County: ______________________________________ Contact Number: ______________________________________ Email: ______________________________________ Contact Name in case of Emergency: __________________________ Contact No: in case of Emergency: __________________________ Are you a member of a cycling club: Yes / No If Yes, which club? __________________________

Please read carefully and sign

DECLARATION
I will abide by the Rules of the Road. I understand and agree that I participate in this sponsored cycle entirely at my own risk, that I must rely on my own ability in dealing with all hazards and ride in a manner which is safe for myself and others. I accept that the function of the cycle stewards is to indicate direction ONLY and that I MYSELF must decide whether my movements are safe. I agree and accept that no liability whatsoever shall attach to the Event Organisers, any Event Official AND/ OR Benefitting Charities in respect of any injury, loss, damage, INCONVENIENCE AND/ OR EXPENSE suffered by me or by any reason of this Event, however caused.

Signature _____________________ Please tick to accept declaration

For Enquiries call 087 2254860