2010 JACKRABBIT STAMPEDE ENTRY
Stampede Information Page
NAME: Last______________________ First_____________________ Middle__________
ADDRESS: Street_________________________ City___________________ State____ Zip________
HOME PHONE: (____) - ___________________ WORK PHONE: (____) - _______________
AGE AS OF 9-11-2010:___________________________________________________________
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 27, 2010
| $20.00
|
| Late: after August 27, 2010
| $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
P.O. Box 1332, Forney TX 75126
ForneyLions@yahoo.com
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 # (___)_____________________________________________________________