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5K-- 25K-- 50K- 100K Rides
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| Name: | ______________________________________________________________________ | |||
| Address: | ______________________________________________________________________ | |||
| ______________________________________________________________________ | ||||
| Phone: | __________________ | Email address: | __________________ | |
| Age on day of ride: | __________________ | If under age 18, Parent/Guardian must sign below* | ||
| Emergency Contact | Name and Telephone: | ________________________________________________ | ||
| Fees: | Pre-reg. $20 by 9/22/07 ________ | Day of Ride $25 ________ | ||
| I Pledge to raise at least $100, due by day of Ride ________ (Waive my registration fee) | ||||
| Make checks payable to: Newport Public Library/ Ride to Read | ||||
| I plan to ride the: | 5K _____ | 25K _____ | 50K _____ | 100K _____ |
| Ghost Ride _____ | ||||
| T-shirt Size: | Med. ____ | Lg. ____ | X-L ____ | |
| 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 Newport Public Library, 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: ________ | |||
| *Parent/Guardian of Minor under Age 18 | _____________________________ | Date: ________ | |||
To register, print this page, and mail to: Newport Public Library 316 N. 4th St., Newport PA 17074