2010 JACKRABBIT STAMPEDE ENTRY


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    __ 62mile      


ENTRY FEE ENCLOSED: Postmarked on or before August 27, 2010		$20.00
                    Late: after August 27, 2010				$25.00

                                       ______________________________________
                                      |       Make checks payable to:        |
 HOW DID YOU OBTAIN THIS FORM?        |          Forney Lions Club           |
  __ requested by mail                |             and mail to:             |
  __ unsolicited mail                 |                                      |
  __ by FAX                           |           Forney Lions Club          |
  __ via the internet                 |                                      |
  __ other:_____________________      |  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 UNDERSTAND 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 # (___)_____________________________________________________________