2009 JACKRABBIT STAMPEDE ENTRY
Stampede Information Page




NAME:  Last______________________ First_____________________ Middle__________

ADDRESS: Street_________________________ City___________________ State____ Zip________

HOME PHONE: (____) - ___________________ WORK PHONE: (____) - _______________

AGE AS OF 9-12-2009:___________________________________________________________


ADULT T-THIRT SIZE:       __ Medium    __ Large    __ Xlarge    __ XXlarge    __ XXXlarge


I WILL RIDE IN:   __ 15 mile      __ 40 mile    __62 mile     


ENTRY FEE ENCLOSED:
Postmarked on or before August 28, 2009 $20.00
Late: after August 28, 2009 $25.00

HOW DID YOU OBTAIN THIS FORM?
__ requested by mail
__ unsolicited mail
__ by FAX
__ via the internet
__ other:_____________________ 		                              

Make checks payable to:
Forney Lions Club
and mail to:

Forney Lions Club
Attn: Mark Madrid
P.O. Box 1332, Forney TX 75126
972-564-3247
Form may be photocopied for
additional applications

NO REFUNDS






WAIVER OF CLAIM BELOW MUST BE SIGNED

















WAIVER OF CLAIM

Please read carefully, must be signed.



In consideration of the acceptance of this entry, I the
undersigned, assume full and complete responsibility for any
injury or accident which may occur to me on the way to,
during, or on the way from the Jackrabbit Stampede or while
I am on the premises of the event and I hereby release and
hold harmless the Forney Lions Club, and entities associated
with such event from any and all claims and liablities I or
my guest or any one or more of my or their executors,
administrators, heirs, next of kin, successors or assignees
have or assert for any injury or damages sustained by me or
my personal possessions, whether same be caused by
negligence of the said entities, myself, or any other person
or entity.   I understand that a bicycle is a legal vehicle in the
State of Texas and that I must ride in a legal and safe manner.
I acknowledge that I am familiar with the dangers involved
in participating in such event, that there may be holes in the
riding surface or other permanent or temporary obstacles
which I must be careful to avoid and agree to familiarize
myself with the course prior to commencement of such event
and recognize that there may be vehicular traffic along
same during the running of the event.   I further certify that I
am in good physical condition and am fully able to
participate in this event.   I also grant full permission to any
and all sponsors to use photography and records of this event
for any purposes.


I HAVE READ AND UNDERSTOOD ALL OF THE ABOVE.

Signature:_______________________________________________________________

Date:____________________________________________________________________

Signature of Parent:_____________________________________________________
(If participant is under 18 years of age on the day of the event.)



In case of accident call:_________________________________________________


Phone # (___)_____________________________________________________________